Inspection on 14/03/06 for Woodlands

This inspection was carried out on 14th March 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodlands 08/05/07

Woodlands 25/07/06

Woodlands 22/09/05

Woodlands 22/02/05

Woodlands 01/09/04

Woodlands 02/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Woodlands Well Park Road Drakewalls Gunnislake Cornwall PL18 9ED Lead Inspector Philippa Cutting Announced Inspection 14th March 2006 09:30 Woodlands DS0000044246.V276130.R01.S.doc Version 5.1 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 DS0000044246.V276130.R01.S.doc Version 5.1 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 DS0000044246.V276130.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Woodlands Address Well Park Road Drakewalls Gunnislake Cornwall PL18 9ED 01822 832451 01822 833305 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) The Regard Partnership Limited Julie Ann Callaghan Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Woodlands DS0000044246.V276130.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 5 people with a learning disability (LD) aged between 16 and 25 years. 22nd September 2005 Date of last inspection Brief Description of the Service: Woodlands is an older style detached property set in its own grounds in the rural village of Gunnislake, on the edges of the moor. It is approximately 20 minutes from the nearest town at Tavistock and a further 20 minutes onto Plymouth. Gunnislake has rail & bus connections with the southwest. The home is owned by The Regard Partnership and provides care and accommodation in single rooms for up to five younger people with a learning disability. It aims to concentrate on promoting independent living & social skills that will enable the service users to ultimately move on to a more independent life, rather than providing a permanent home. To this end high staffing levels are required, usually at least one:one. Woodlands DS0000044246.V276130.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection that took place between 09.45am & 4.15pm. The inspection encompassed discussion with the registered manager and other staff, a tour of the premises, meeting service users and inspection of records and systems. The registered manager has set up systems that cover both adults and children as the current registration permits the accommodation of minors over the age of 16 years. The overhaul of the files and service users’ notes has consolidated the improvement that was noted at the previous inspection in September 2005. The inspector gained the impression that The Regard Partnership (TRP) has now put policies and procedures in place to assist the properties it operates. These appeared to be lacking when TRP took over the home originally. The registered manager advised that she was leaving the home for another position but that a new manager had been identified so that hopefully the change over would be smooth. All staff have had opportunities to undertake much needed training to increase their understanding of learning difficulties and behaviours that may be associated with it. What the service does well: What has improved since the last inspection? A process for assessing potential clients has been put in place, which appeared to be thorough and comprehensive. Records for staff and service users have been reviewed and updated so that they now meet the national minimum standards requirements. The staff team has consolidated and become focused. Everyone has had an appraisal and regular supervision. Any instances of unsatisfactory work practices have not been condoned. Woodlands DS0000044246.V276130.R01.S.doc Version 5.1 Page 6 Regular visits under regulation 26 have started taking place. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodlands DS0000044246.V276130.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodlands DS0000044246.V276130.R01.S.doc Version 5.1 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 the following standard(s): 1,2,3,4 Information about the home has been updated and is available for all interested parties. Further revisions are in hand to make the information easier to read. The home demonstrated that the information sought about prospective service users was full with satisfactory procedures in place for a new service user to visit as part of the decision/admission process. EVIDENCE: The home’s statement of purpose & service users guide has been revised. A new service user’s handbook is being prepared to accompany the service users guide. This is being prepared in a colourful format with pictures to clarify topics. The pre admission assessment for a new service user was seen. This was thorough and the registered manager had obtained full information from other professionals who have been involved. The registered manager said that she has been careful in offering care & accommodation to potential clients, as she has, correctly, considered the needs of the exiting service users as part of the assessment. The new service user has visited the home for a number of varying occasions prior to making a decision about moving in. There was a discussion about the fee structure. The registered manager said that this was determined by The Regard Partnership (TRP) officers, based on Woodlands DS0000044246.V276130.R01.S.doc Version 5.1 Page 9 the needs assessment. The benefits section at TRP deals with the financial matters relating to a placement. Woodlands DS0000044246.V276130.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10 It was evident that service users are included in planning the routines and running of the house. They have opportunities to express their views, which are taken into careful consideration when decisions are made. Service users are encouraged to make - and follow through – choices. Any risks that might be attached to theses choices are evaluated and documented. EVIDENCE: Needs, aspirations and difficulties are discussed with service users as much as possible. Inevitably some are able to participate more than others but people know they can ask to speak to a member of staff if they wish. Discussions are documented and any decisions signed by both the staff member and service user to demonstrate their content. To this end the service users’ plans have been fully revised, with risk assessments included where necessary. The home holds regular house meetings where comments from service users and staff are invited and considered. Woodlands DS0000044246.V276130.R01.S.doc Version 5.1 Page 11 Families and important other people are involved in planning people’s needs. The amount of involvement varies according to individual circumstances and sometimes distance, but opportunities are offered. A system that rewards and provides incentives for positive behaviour has recently been introduced. So far this is proving successful and appears to have reduced the number of incidents that might otherwise have been recorded. Woodlands DS0000044246.V276130.R01.S.doc Version 5.1 Page 12 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 the following standard(s): 11,12,13,14,15,16,17 The ethos of the home is directed at helping service users become more independent in all aspects of their lives. Staff provide assistance at all times but a service user’s wish to have some personal time is respected. People are involved in activities both in Woodlands and the wider community. EVIDENCE: All staff work hard to provide service users with opportunities to learn, practice and extend their life skills. The opportunities for work experience and creative leisure are somewhat limited in the immediate area but those further afield in Plymouth & Tavistock etc. are explored and utilised as much as possible. Some problems in setting up schemes have been hampered by wrangling over funding or waiting for feedback from other sources outside the home. Each service user has a weekly programme. This is displayed so that the service user and staff know what is planned whether people are at Woodlands or out. The registered manager said that staff were planning to start ‘life stories’ with service users. Woodlands DS0000044246.V276130.R01.S.doc Version 5.1 Page 13 Service users need one:one staffing, sometimes two:one when out. Staff frequently have to remind service users of the time and need to get up to be ready for their various activities. The service users are expected to attend to various personal chores each day. Help or supervision is provided as needed. Service users are made aware of this prior to admission. Contact with families and friends is encouraged unless there are cogent reasons for this to be limited, in which case this would be documented following agreement with the service user’s social worker or other relevant person. Service users help prepare and clear away after meals. The menus are planned jointly with the service users and staff. A choice is offered for the main meal, which is normally taken together in the evening after people have returned from daytime activities. Woodlands DS0000044246.V276130.R01.S.doc Version 5.1 Page 14 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 the following standard(s): 18,19,20,21 The physical, psychological and emotional needs of service users are addressed with them, specialist advice being sought when ever needed. EVIDENCE: Currently all the service users are in good physical health. Specialist input is sought as needed and the registered manager reported that the GP with whom service users are registered was helpful and supportive. The local Learning Disability team provides advice and assistance as needed. All service users have had their medication reviewed and some changes have been introduced with the aim of reducing medication to the least amount needed. Staff have attended a course provided by TRP on the safe handling of medication. It is administered via the monitored dose system and fully recorded. The inspector advised that a note should be made regarding changes to one person’s medication as the dose prescribed is reducing which means there will be tablets left over in the blister pack at the end of each month. Staff reported that the service users are compliant with taking medication. The home has TRP’s policies on ageing, illness & death but the registered manager said, in discussion, that she felt this was unlikely to apply the service Woodlands DS0000044246.V276130.R01.S.doc Version 5.1 Page 15 users at Woodlands as all are in a younger age bracket and Woodlands is not intended as a permanent home but a ‘move on’ establishment. Woodlands DS0000044246.V276130.R01.S.doc Version 5.1 Page 16 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 the following standard(s): 22,23 PoVA & PoCA systems are in place and staff have received training regarding these procedures. The home’s complaints system is provided in different formats according to individual need. EVIDENCE: The home has a complaints procedure that is available to all service users. It has been produced in a symbol form where this is needed. There have been no complaints from service users since the last inspection. The registered manager commented that two of the service users regularly speak out if something is concerning them. A complaint from a Social Worker was addressed and a PoVA meeting was held as part of the process. The complaint was substantiated in part. Woodlands DS0000044246.V276130.R01.S.doc Version 5.1 Page 17 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 the following standard(s): 24,25,26,27,28,29,30 The home is much improved due to redecoration. Service users are encouraged to help maintain their environment, which meets the needs of the current group. A planned extension will need very careful organisation if service users are to remain in residence during building works. EVIDENCE: The home has been extensively redecorated with new carpets & furnishings provided. Service users have personalised their rooms according to their taste. Some reallocation of rooms has taken place, which has pleased the people concerned. The three occupied rooms were clean and tidy. The improvement in one room in particular suggested that the occupant was happy with his accommodation. A previous concern regarding the most used entrance being via the kitchen has, the inspector was told, been discussed with the Environmental Health Officer during a recent visit. This officer did not feel this created a problem but it is an issue that may be addressed in the planned extension that has been granted planning permission. An extension will also relocate the office, as, at Woodlands DS0000044246.V276130.R01.S.doc Version 5.1 Page 18 present, privacy and confidentiality has to be monitored carefully if people are in the kitchen when discussions are taking place in the current office. There is a sitting room, dining room & small sun lounge on the ground floor for communal use. The dining room is not well appointed as the boiler and a freezer are sited there. This may also be addressed in any building programme. Externally the grounds looked much improved with general maintenance and tidying up having been accomplished. The staff said that everyone liked using the gardens in good weather. The building plans are ambitious, planning to double the accommodation by means of a large extension. Considerable thought needs to be given to how this will be accomplished without compromising the needs of the current service users and bearing in mind the health & safety constraints that living on a building site will create. Woodlands DS0000044246.V276130.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36 The staff have become a focused team who have received training to enable them to work with, and support, the service users appropriately. EVIDENCE: 17 staff are currently employed. Staff files have been fully updated. An extensive training programme has been in progress for all staff. Those with whom the inspector spoke were very positive about it. The training has covered topics specific to the Woodlands client group and National Vocational Qualifications at levels ll & lll. Criminal Records Bureau checks are obtained for all new staff before they start work, although they may be able to shadow existing staff until satisfactory checks are received. TRP is setting up a Human Resources department that will undertake future recruitment. Staff receive regular documented supervision and all have had an annual appraisal. New staff are also required to serve a probationary period before becoming permanent staff members. Woodlands DS0000044246.V276130.R01.S.doc Version 5.1 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,43 There has been significant improvement in the management of the home both internally by the registered manager and the support now provided by TRP. 12 months ago Woodlands was failing to meet many of the national minimum standards but this position has now been reversed. EVIDENCE: The current manager is experienced in the field of learning disability and has completed her registered manager’s award, awaiting verification of her portfolio. She has established proper and cohesive systems to ensure that the home complies with current legislation and guidance, which was lacking when she took over. She is however now leaving and a new manager has been identified to take over. The deputy manager is experienced and is also undertaking her registered manager’s award. The home has the policies and procedures of TRP in place. The registered manager said that they were planning to provide a second copy in an Woodlands DS0000044246.V276130.R01.S.doc Version 5.1 Page 21 alternative format so that service users could read and understand them as well. Records required by statute are in place and kept up to date. These include accident records, fire records, insurance and maintenance certificates. Health & safety is reviewed annually with regular weekly checks by a designated member of staff although everyone retains a responsibility for maintaining a safe environment. TRP has recently appointed a senior member of the organisation to be responsible for quality assurance within the group and he has conducted a review of the services provided by Woodlands. The inspector received a copy of this report and a comment card from one service user’s family. This had positive comments about the home. As part of the TRP, Woodlands is included in their overall financial management. Currently in its own right Woodlands is not within its allocated budget as it has carried two empty places and embarked on training and refurbishment in the last 12 months. However the benefits of this programme are now apparent. Woodlands DS0000044246.V276130.R01.S.doc Version 5.1 Page 22 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 3 3 3 4 3 5 X 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 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 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 3 3 X 3 Woodlands DS0000044246.V276130.R01.S.doc Version 5.1 Page 23 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. 1 Standard YA24 Regulation 39 (h) Requirement The registered person is required to give the Commission notice in writing of the action it proposes to take to protect service users and staff during any building works, prior to the commencement of any such work. Timescale for action 31/04/06 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 YA20 Good Practice Recommendations Details of one service user’s medication should be recorded clearly showing that the reducing dose will result in surplus medication at the end of each month. The surplus must be accurately recorded. Woodlands DS0000044246.V276130.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 Woodlands DS0000044246.V276130.R01.S.doc Version 5.1 Page 25 - 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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