Inspection on 17/10/07 for Woodlands

This inspection was carried out on 17th October 2007.

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 05/01/07

Woodlands 30/11/05

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Woodlands Blundell Avenue Freshfield Formby Merseyside L37 1PH Lead Inspector Ms Lorraine Farrar Key Unannounced Inspection 17th October 2007 12:10 Woodlands DS0000063026.V347341.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 DS0000063026.V347341.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 DS0000063026.V347341.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Address Blundell Avenue Freshfield Formby Merseyside L37 1PH 01704 872179 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) woodlandsunit@yahoo.co.uk www.ftf.org.uk The Frances Taylor Foundation Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Woodlands DS0000063026.V347341.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th January 2007 Brief Description of the Service: Woodlands is owned and operated by the Francis Taylor Foundation, a national organisation who provide services for people with a variety of support needs. It provides accommodation and support with nursing for 12 adults who have a learning disability. Many of the people living there also have physical disabilities and the service provides aids and adaptations to meet their needs. There are care staff available 24 hours a day. During the day there is a registered nurse in the home, whilst at night they share the registered nurse with the two other homes located nearby. Woodlands is located in the middle of Formby Pinewoods and shares the site with, two other registered homes, a day centre for 65 people and a convent. All the services are for adults who have a learning disability. Services share transport, kitchen facilities, large grounds and some administrative support. Most of the bedrooms are single rooms, where two people share, there are screens provided for privacy. Where needed, everyone living there has their own toilet, which is either in or near to, their bedroom and is adapted to meet their needs. There is a dining room, several lounges, bathrooms and a small kitchen within the home and a small, private, courtyard outside for people to share. It costs £945 per week to live at Woodlands. Woodlands DS0000063026.V347341.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Information for the inspection was gathered in a number of different ways. This included an unannounced site visit for 7 hours on 17th October 2007, where time was spent reading records and looking at the building. A system called ‘case tracking’ was used as part of the visit. This involves looking at the support a person gets from the service including their care plans, medication, money and bedroom, time is also spent meeting with the person and with staff about how they meet the persons needs. Case tracking was used to look at life in the home for three of the people living there. Discussions took place with two relatives and three members of staff. We also spent time meeting with some of the people who live there and observing daily life in the home. Comment cards were sent out before the inspection to some of the people living there and their relatives. Two relatives replied and their comments were taken into account in writing this report. The manager contributed to the inspection process by completing a selfassessment form. The information gathered from the site visit along with any information about the home, that we have received since the last key inspection, has been used to write this report. What the service does well: The people who live at Woodlands get good support to maintain and monitor their health and their personal care. Staff have a good understanding of people needs and choices in this area and are able to explain how they meet these. Relatives of the people living at Woodlands say that people get consistently good support in these areas. Staff work in partnership with peoples relatives and friends, involving them in decisions about their relative, listening to their views and inviting relatives to take part in outings and holidays as well as visiting the home or supporting the person to visit their relatives. Clear systems are in place for raising and dealing with any concerns or allegations that arise. Relatives said that they are aware of these systems and do get a response to any concerns that they raise. An easy to understand copy Woodlands DS0000063026.V347341.R01.S.doc Version 5.2 Page 6 of the complaints procedure is available for the people who live there or anyone considering moving in. This helps to ensure that everyone can understand as much as possible about how the home works. People can personalise their bedroom with décor and furniture as well as their hobbies and staff take time to chat with people and support them with the things they enjoy as well as with their personal care. All areas of the home are accessible to people who have physical disability and there are a number of aids and adaptation available to support people with their mobility and their personal care. The manager is clear about her role in supporting the people who live at Woodlands and staff. She has a sound knowledge of how the service operates and plans for future improvements that will benefit those who live there. What has improved since the last inspection? Since the last big inspection of Woodlands in January 2007 staff have undertaken several training courses to enable them to support the people who live there safely and well. This includes learning sign language and supporting people who have a peg feed. Time and money have been invested into making shared areas of the home look more comfortable and inviting. The dining room and living areas have been refurbished and decorated. In addition all areas looked well cared for and homely. The people who live at Woodlands receive more support to get out and about in their local community and attend community events such as pop concerts and meals out. Meal times are better organised with people having a choice of meals and staff taking time to sit with people on a one to one basis and support them quietly to complete their meal. Tables are nicely laid and inviting and encourage people who are more independent to enjoy their mealtime. Regular health and safety checks including fire drills and the testing of small electric appliances are now carried out. This helps to ensure Woodlands is a safe place for people to live and work in. Woodlands DS0000063026.V347341.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Woodlands DS0000063026.V347341.R01.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 Woodlands DS0000063026.V347341.R01.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient information is obtained about and provided to people considering moving into Woodlands. This helps everyone to decide if it is the right place for the person to live. EVIDENCE: Nobody new has moved into Woodlands since the last big inspection took place. However the manager was able to explain that before offering anyone a place to live she would carry out a full assessment of their needs and ensure they had visited the service. People would also be offered the opportunity to stay overnight and have a trial period living there. A policy is in place for staff to follow when new people are considering moving in, this guides staff on the steps to take to ensure sufficient information has been obtained about and given to new people to help them make a decision. This helps to make sure that Woodlands can meet not only the persons needs but also their choices. Woodlands DS0000063026.V347341.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff who support the people living at Woodlands have a good understanding of their basic needs and choices. However a lack of overall planning may lead to these not being consistently recognised and met. EVIDENCE: An individual care plan is in place for all of the people living at Woodlands. Three of these were looked at during the site visit and all had been recently reviewed and if needed updated. This helps to make sure that any changes to the persons support needs or their choices are noted and can be acted upon. Care plans contain information about the support the person needs with their personal and health care and gave some detailed information about how to provide this. For example one plan contained information about making sure the person is positioned safely and correctly whilst in bed and photographs had been included to guide staff. Woodlands DS0000063026.V347341.R01.S.doc Version 5.2 Page 11 There is however limited information about how the service identify and meet peoples social needs or about the way the person communicates their choices. As most of the people who live at Woodlands use non verbal forms of communication, this could lead to unfamiliar staff not understanding as much as they should about the person, their communication methods and their choices. Staff explained that the organisation are in the process of putting together a more person centred format for care planning. Samples of this were seen for one person and once completed for everyone they will provide clear information about not only the persons support needs but also their lifestyle choices and how staff are supporting them to meet these. All care plans looked at contained copies of risk assessments for the person. These covered areas such as the use of equipment and supporting the person with their health. Clear information was recorded about risks to the person along with guidance for staff to follow to prevent or reduce the risk occurring. All had been recently updated and reviewed. Although care plan information was limited around the choices and decisions that people can make in their daily lives, discussions with staff and relatives and observing daily life at Woodlands showed that people are supported to make decisions wherever possible. Staff were able to explain how people communicate the things they like to do and when the do not wish to do something. A relative spoken with explained that she is consulted about things that affect her relative. Explaining for example, that she had helped her relative to choose new décor and furnishings for her room. Woodlands DS0000063026.V347341.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people who live at Woodlands are generally supported to live a lifestyle of their choosing. Increased access to more everyday community based activities would enhance this further. EVIDENCE: There are several facilities on the site that the people who live at Woodlands can access. This includes a day service that many of the people living at Woodlands attend four days a week. Whilst there they can spend time with people who live at other care homes on the site and people who live in the wider community. They can also participate in a number of activities and outings. A hydrotherapy pool is also available. This is an excellent facility that is well equipped to meet peoples physical support needs. The people who live at Woodlands are able to use the pool with staff from the day service or occasionally with staff who work at Woodlands. Woodlands DS0000063026.V347341.R01.S.doc Version 5.2 Page 13 There is also a large hall on site that holds Catholic and Christian services regularly. A relative explained that people’s friends and relatives are also able to attend these services if they wish. The manager explained in her pre inspection form that they are currently trying new activities for the people living there. This was evident during the site visit when advertised events leading up to Christmas included, attending a pop concert, an on site musical evening, a pantomime and a Christmas meal out with family, friends and staff. As well as these planned outings staff support people to use community services such as the optician and hairdressers rather than these services visiting the home. This enables people to get to know and to take part in their local community more. However none of the people living there currently attend community facilities such as a college or club regularly. This would give people the opportunity to meet new people and possibly build relationships within their wider community. Staff were seen to spend time supporting people to do things they enjoy such as listen to their music alone, watching TV with others or going for a walk. Staff were also seen to take time to sit and chat with people as well as meeting their basic support needs. The service tries to work in partnership with relatives and this was evident during the site visit when relatives were seen to support the person they were visiting. One relative explained that she is invited to go on outings with her relative and explained, “it’s like a second home, she’s happy here and so am I”. A central kitchen provides the main meals for all the services on site. There is also a small kitchen at Woodlands, which can be used to prepare breakfast, drinks and snacks. There is a choice of three meals at lunch and teatime and the main kitchen will cater for special diets. In discussions with one of the people living at Woodlands she indicated that the quality of the meals was variable, at times they are enjoyable at other times not so good. The manager acknowledged this and explained that she is planning to meet with the head chef to discuss meals. Woodlands does not hold a food budget of its own, the main kitchen provides snacks and drinks as and when requested. None of the people living there are currently engaged in spending time shopping for or preparing drinks or meals. This limits the opportunities people have to spend time learning everyday skills or having new experiences. Woodlands DS0000063026.V347341.R01.S.doc Version 5.2 Page 14 The manager explained in her pre inspection form that more leisurely meal times have been introduced to the service. This was evident during the evening meal, part of which was observed. Dining tables were nicely laid with cloths, matching crockery and cutlery and facilities to pour a cup of tea. Staff were seen to support people on a one to one basis and to take their time to chat with the person and ensure they had the time to enjoy their meal. The overall atmosphere was calm and relaxed with people clearly enjoying the time taken. Woodlands DS0000063026.V347341.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living at Woodlands receive a good level of support to identity and meet their health and personal care needs. EVIDENCE: A relative of one of the people living at Woodlands explained in her comment card that “(our relative) is very happy at Woodlands and is well cared for” and another relative said during the site visit that, “they get very good care”. Records showed that people are supported to access and get to health care appointments. This includes regular appointments such as seeing the optician and dentist as well as more specialist appointments such as hospital visits and accessing equipment services. Daily records showed that staff provided support to people on a daily basis with both their personal care and health care needs. Equipment is provided to meet peoples needs and help prevent health issues occurring. This includes arranging for specialist chairs ad wheelchairs and for people to have mattresses and cushions, which help their skin to remain in good condition. Woodlands DS0000063026.V347341.R01.S.doc Version 5.2 Page 16 Clear records help staff to maintain an overall view of how people health has been. For example if someone has a seizure this is clearly recorded so that any changes or increases are quickly noted and can be acted upon. During the site visit staff were seen to offer people support with their personal care discreetly and it was evident when meeting the people living there that they had been supported to choose clothes that were both suitable and appropriate for their needs and choices. Records also showed that people are supported to get up or go to bed at times suitable to their plans for the day and that they choose. There is a separate room to store medication at Woodlands and this was seen to be clean and tidy. Care plans contain information about the support people require with their medication. Where it is given with their food this is clearly documented, agreed by relevant people and the reasons why are clearly recorded. This helps to ensure the process is clear and people are given their medication in a way that is right to meet their health care needs. Records of medication given to people and received into the home are clearly recorded and samples of medication checked tallied with these. This helps to ensure there is a clear audit trail and people are receiving their medication as prescribed. During the evening meal staff were seen to give people their medication quietly and discreetly and at a time that met their needs as identified within their plan of care. Woodlands DS0000063026.V347341.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clear systems are in place for dealing with any concerns or allegations that arise. EVIDENCE: Relatives of the people living at Woodlands said that they know how to raise any concerns they may have and that they do receive a response to these. Information about the organisations complaints procedure is available in the foyer with a picture format also available to help the people living there understand as much as possible about it. Information about the local authority adult protection procedures is readily available and staff have received training in this area. Staff spoken with were able to explain the actions they could and would take if they had any concerns regarding the service provided. Clear systems are in place for supporting people to manage their money. Records and receipts are kept of purchases made, a sample of which were checked and tallied. Woodlands DS0000063026.V347341.R01.S.doc Version 5.2 Page 18 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, 27, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Woodlands provides people with a comfortable home to live in that meets their needs and choices. EVIDENCE: A number of areas of Woodlands have been decorated in the past few months and a relative expressed the opinion that “its nice and homely now”. The home provides ten single bedrooms and one double room with screens provided for privacy. In addition people share a large dining / living room and several small lounges or seating areas. These communal rooms have mostly been decorated to a good standard with new furniture and carpets provided. Where new furniture has not been has not been purchased staff have made the areas look homely with cushion covers, throws and pictures. Woodlands DS0000063026.V347341.R01.S.doc Version 5.2 Page 19 The manager explained that there are plans in place to provide another single room so that nobody has to share and also to provide an accessible shower so that people have a choice with regards to their personal care. She also explained that they are hoping to decorate corridors within the next few months. Peoples bedrooms are very well decorated and furnished in accordance with their needs and choices. Staff and relatives support people to personalise their rooms with photos, posters and music and TV’s as they prefer and people where seen to enjoy spending time in their room engaged in their preferred activities. There are three adapted bathrooms within Woodlands all of which provide bathing facilities to meet the needs of people with physical disabilities. In addition everyone has an en-suite or designated toilet that has aids and adaptations fitted specifically to meet their needs. Due to the layout of the home all areas are accessible to people with physical disabilities, with wider corridors and doorways. However the small kitchen area is not adapted to the needs of people who use a wheelchair, work surfaces and equipment are all at a height that may prevent people from using them and so limit their opportunities. Outside Woodlands has a small courtyard with seating, they also share extensive grounds with the other services on site. This includes several gardens and areas to walk. Many of the windows within the home have a pleasant view of the local sand dunes and wildlife. There is a designated laundry room, which is well equipped to meet the needs of the people living there and has a clear system in place for preventing any cross infection occurring. All areas of the home seen during the site visit were warm, clean and tidy. Staff take the time to ensure that the home looks as welcoming and homely as possible. Woodlands DS0000063026.V347341.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living at Woodlands are supported by a competent staff team who are able to identify and meet their needs and choices. EVIDENCE: Relatives spoken with and who completed comment cards all said that they think staff have the skills and experience to support the people living at Woodlands and expressed the view that staff provide good support to the people living there. One relative wrote “I would hope that you would convey to all concerned my deepest appreciation for the care shown to my (relative) through all this time.” Another said that they think staff do “a tremendous job” and a third described them as “marvellous”. During the site visit staff spoken with displayed a good knowledge of the people they support and their individual support methods and choices. Staff were seen to spend time talking with people as well as providing the more practical support that they required. Woodlands DS0000063026.V347341.R01.S.doc Version 5.2 Page 21 Several of the care staff hold a care qualification (NVQ) and others are working towards obtaining this. This helps to ensure staff are up to date with current good practice and can support people safely and well. Records and discussions with staff showed that they have undertaken a number of training courses to help them in their work and in supporting those who live at Woodlands. These range from basic courses such as moving and handling people and the protection of vulnerable adults, to more specialist training such as use of the hydrotherapy pool, the new mental capacity act and supporting people who challenge. Records showed that before anyone begins work at Woodlands a series of checks are carried out to help ensure they are suitable to support the people who live there. This includes a set interview process, obtaining references and carrying out checks with the Criminal Records Bureau (CRB) and protection of vulnerable adults list. Woodlands DS0000063026.V347341.R01.S.doc Version 5.2 Page 22 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, 38, 39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Woodlands is safely managed for the people who live there. A lack of documented planning may lead to service improvements not being noted and carried out. EVIDENCE: Mrs Diane Ellis is the appointed manager of Woodlands. She is not yet registered with the Commission for Social Care Inspection but is aware of the need to do so. This registration helps to ensure that care home managers are suitable people to manage a service. Mrs Ellis is experienced in a management role within a care setting, is a registered Nurse and has undertaken a course in supporting adults who have learning disabilities. Records showed that she takes part in regular training Woodlands DS0000063026.V347341.R01.S.doc Version 5.2 Page 23 courses to ensure her knowledge is up to date. She explained during the site visit that she also intends to undertake a management qualification. There are clear lines of accountability within the organisation and within Woodlands. During the site visit the manager displayed a clear understanding of her role and a firm commitment to planning and working towards improvements to the service that will benefit those who live there. There are some systems in place within Woodlands for checking the quality of the service they provide. These include regular reviewing of care plans and auditing of medication. However the organisation have not carried out a full quality assurance review of the service since April 2006. The document used is based on national standards for care and if used and kept up to date provides a clear way to identify, plan and carry out service improvements. In addition to this the views of the people living there and their relatives should be obtained as to the things they think the service does well and the things they would like to see improved. No evidence that their views had been recently sought was available. Records and certificates showed that regular checks are carried out on the environment and equipment to ensure they are safe to use. This includes checks on the fire system, moving and handling equipment and the mains electrics. Woodlands DS0000063026.V347341.R01.S.doc Version 5.2 Page 24 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 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 2 25 X 26 3 27 3 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 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 3 15 4 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 3 2 X X 3 X Woodlands DS0000063026.V347341.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA39 Regulation 24 (1) Timescale for action A system for regularly reviewing 30/01/08 the quality of the service must be implemented and reviewed. This will help to ensure that future improvements are planned, carried out and reviewed. Requirement 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 OP7 Good Practice Recommendations A section should be include in all care plans identifying the decisions that the person can make and how staff can support them with these. This will ensure everyone is aware of the persons communication methods and can identify their choices with them. DS0000063026.V347341.R01.S.doc Version 5.2 Page 26 Woodlands This is a previous inspection recommendation 2. YA39 The quality audit system should be reviewed to ensure it includes service users experiences of life in the home. This will help to ensure Woodlands operates in the best interests of the people living there. This is a previous inspection recommendation 3. YA13 Staff should explore opportunities for daytime activities with people in their wider community. This will increase peoples opportunities to become part of their local community and meet new people. 4. YA17 Consideration should be given to Woodlands holding a small food budget. This would support some of the people living there to increase their everyday living skills and experiences. Consideration should be given to altering the design of the kitchen to provide more accessible facilities. This will increase people opportunities to take part in and observe everyday activities. The manager should apply to the CSCI to become registered as the Manager of Woodlands. This will help to ensure that she is a suitably qualified and experienced person to manage the home. 5. YA24 6. YA37 Woodlands DS0000063026.V347341.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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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