Inspection on 21/09/09 for Woodlands

This inspection was carried out on 21st September 2009.

CQC found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodlands 23/09/08

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report CARE HOME ADULTS 18-65 Woodlands Leamington Road Barton Hills Luton Beds LU3 3XF Lead Inspector Nicky Hone Unannounced Inspection 21st September and 24th September 2009 13:20 Woodlands DS0000071719.V377797.R01.S.doc Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Woodlands DS0000071719.V377797.R01.S.doc Version 5.3 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Woodlands DS0000071719.V377797.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Woodlands Address Leamington Road Barton Hills Luton Beds LU3 3XF 01582 564780 01582 564782 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) TACT UK Ltd Mr Mohamed Naguib Fuzurally Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Woodlands DS0000071719.V377797.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning Disability - Code LD The maximum number of service users who can be accommodated is 5 2. Date of last inspection 23rd September 2008 Brief Description of the Service: Woodlands is a home for up to five adults with learning disabilities. TACT UK Ltd (now known as Affinity Trust) has managed the home since March 2008. The bungalow is owned by MacIntyre Housing Association (MHA), which is responsible for the maintenance and upkeep of the building. The home is situated in a well-established residential area of Luton, with access to local shops as well as to town centre facilities and good public transport links. About 3 years ago, Woodlands was completely refurbished to a very high standard. The building is a large bungalow, which is suitable for people who may have a physical disability. Each service user has their own bedroom with an ensuite bath or shower. Two of the bedrooms also have their own kitchen and lounge facilities. During the last year, these kitchen facilities have been enhanced to give these 2 people a proper kitchen. Communal space consists of a large lounge, activity room, quiet room, and a good-sized kitchen/diner. Office, storage, laundry and additional bathing facilities are also provided. There is a garden to the rear of the building and a number of parking spaces to the side of the home. Full information regarding the fees, including any additional charges, was not known at the time of writing. Woodlands DS0000071719.V377797.R01.S.doc Version 5.3 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. For this inspection we (the Care Quality Commission) looked at all the information that we have received, or asked for, since the last inspection of Woodlands. This included: - The AQAA (Annual Quality Assurance Assessment) that the manager completed and sent to us in July 2009. The AQAA is a self-assessment that focuses on how well outcomes are being met for people living at Woodlands. It gives the provider the opportunity to say what the home is doing to meet the standards and regulations, and how the home can improve to make life even better for the people who live here. The AQAA also gives us some numerical information about the service; - Surveys which we sent to the home to give to the people who live here. We received 2 replies: these were both completed by staff; - Surveys for staff which we sent to the home: we received 4 replies; - What the service has told us about things that have happened in the home. These are called notifications and are a legal requirement; - Any complaints and safeguarding issues that have arisen; and - Information we might have asked the home to send us following our visit. This inspection of Woodlands also included two visits to the home on 21st and 24th September 2009. No-one who lives or works at the home knew we were going to visit on the first day and the registered manager was on leave. One of the staff was very helpful but as there was some information he was unable to show us, or did not know about, we arranged to return on the second day to meet the manager. Over the 2 days, we spent time talking to staff and the manager. We looked round the home and spent time in the bungalow, observing what happens. We spoke briefly with two of the people who live here: the other two people do not use words to communicate. We looked at some of the paperwork the home has to keep including care plans, risk assessments, medication charts, staff personnel files, rotas, menus and fire test records. TACT UK Ltd has changed its name to Affinity Trust. At the time of this inspection, CQC was in the process of issuing new certificates to all the Woodlands DS0000071719.V377797.R01.S.doc Version 5.3 Page 6 services. We understand that there have been discussions about the future of this service. Proposals have been put forward that it would be in the best interests of the people who live here to make this supported living accommodation rather than a registered care home. What the service does well: What has improved since the last inspection? What they could do better: Woodlands DS0000071719.V377797.R01.S.doc Version 5.3 Page 7 We are disappointed that some aspects of the service offered to the people who live at Woodlands are not as good as they were at our last inspection. 2 of the requirements we made last time have not been met. There are a number of ways this home needs to improve. We have made 8 requirements, including: • There must always be enough staff on duty to meet the needs of the people who live at Woodlands, especially so that they are able to carry out planned activities; Medicines must be handled and recorded correctly; People must be offered more to do both at home and in the community; Risks must be assessed so that risks can be minimised and people supported to take risks if they choose to; Information required by the regulations, including a Criminal Record Bureau check, must be obtained for anyone who works at the home; Staff must be trained in all aspects of health and safety, especially moving and handling and infection control; Staff must be trained to do the things they are expected to do such as assist with PEG feeding; and The staff rota must accurately reflect the staffing situation. • • • • • • • If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Woodlands DS0000071719.V377797.R01.S.doc Version 5.3 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 DS0000071719.V377797.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 People using the service experience good quality outcomes in this area. Information is available about the service and assessments are carried out so that people know the home can meet their needs. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home has a service user guide and statement of purpose, so that people thinking about moving here have good information about what the home has to offer. The service user guide includes pictures and symbols and uses easyread language. The fees quoted were not up to date. One of the 2 people who we case-tracked was admitted to Woodlands just over a year ago. We found a detailed assessment on his file, done by the local authority, and information from his previous home. The needs of all the people who live at Woodlands are currently being re-assessed to find out whether their needs could be met better in supported living. Woodlands DS0000071719.V377797.R01.S.doc Version 5.3 Page 10 All 4 people who live here have a contract with Woodlands, for their care and support, and a licence agreement with the housing association for the accommodation. The contracts have been developed in an easy-read format, using pictures, symbols and simple language. They were not personalised: both we looked at stated that the person would have ‘a bedroom with a washbasin’, but both people have a bedroom, a living room with kitchen facilities and an ensuite toilet, washbasin and shower. We noted that the contracts state the cost includes “the cost of social activities” but we found that people were paying for their own activities (see Lifestyle, Concerns, Complaints and Protection, and Conduct and Management sections of this report). Woodlands DS0000071719.V377797.R01.S.doc Version 5.3 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9, 10 People using the service experience adequate quality outcomes in this area. Care plans are written in a person-centred way and contain good detail about the support people need, but they do not include any information about people’s hopes, dreams and goals. Some risks have not been assessed adequately enough. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: On both files we looked at there was a clear, concise ‘pen picture’ about the person with good details about their daily routine. On the file of the person who is very dependent on staff support for everything, there were detailed instructions for staff about supporting this person in all daily activities, for Woodlands DS0000071719.V377797.R01.S.doc Version 5.3 Page 12 example getting up, showering, shaving, transferring on/off the toilet, eating, going swimming and so on. These plans had been regularly reviewed. However, the plans did not include any aims/goals that the person might be working towards. We noted that a recent report by the provider (regulation 26 visit) highlighted that there were no goals identified in the plans. On another file, as well as a care plan, we found that a number of risk assessments had been carried out and recorded, and included management guidelines for staff. The assessments covered areas such as cooking, travelling in the car, bathing, community access, eating, horse-riding and so on. There was no evidence that any risk assessments had been carried out and recorded, around the holiday in Turkey which 2 people went on the day after this inspection. On one file we saw that the speech and language therapist (SALT) has been involved in helping staff learn how to communicate with this person using ‘objects of reference’. This person is blind and does not appear to hear. There was detailed guidance and a lot of ideas about which objects could be used, for example giving the person a knife and fork to show that it is time for a meal, or a toilet roll so he can choose whether he needs the toilet. The SALT also suggested that each staff member should carry an item unique to them that they would always show the person so he knows which staff member is with him. The guidance impressed on staff how important it is that all staff follow this consistently. One staff member said this has not been very successful as the person doesn’t seem to respond. The manager agreed that staff have probably not persevered with this consistently enough, for long enough. Each person has a PCP (Person Centred Planning) folder. This is kept in the person’s room. One we saw was full of good, person-centred information, written using “I”, and included photographs and pictures. The other was not as fully completed but still included good details. People are supported to make decisions about their lives. Each person who lives at Woodlands has a key worker and a link worker. They meet with the person regularly to make sure everything is going well and they are leading the life they want to lead. The home expects these staff to complete a summary each month of any significant events for that person, taken from the daily records, care plans, PCP folders and so on. These had not always been completed in a way that would be useful. An advocacy service, Advocacy Alliance, is involved with people at Woodlands, and an advocate meets people regularly. Woodlands DS0000071719.V377797.R01.S.doc Version 5.3 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 11, 12, 13, 14, 15, 16, 17 People using the service experience adequate quality outcomes in this area. Some of the people living at Woodlands are not offered enough opportunities for things to do either in the house or in the community. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: We were very disappointed in the amount and range of activities undertaken by some of the people who live at Woodlands. Each person has an activity plan for the week ahead but records showed that a number of the activities had not taken place. One of the people whose notes we case-tracked does some activities outside the house, such as horse-riding, piano lesson, a college course, shopping, and Woodlands DS0000071719.V377797.R01.S.doc Version 5.3 Page 14 a session in the snoozelen. From this person’s financial records we saw that this person pays for everything he does. We would expect that some activities would be paid for from the funding received from the local authority, and his contract states that the fees he pays cover the “cost of social activities” (see Choice of Home and Concerns, Complaints and Protection sections of this report). The other person we case-tracked has done very little for several weeks. We were told he has not been well recently in that he has shown some challenging behaviour. This person is almost blind, probably deaf and physically disabled. He does not use speech to communicate. Staff told us he loves going swimming at the local hydrotherapy pool, so is booked to go twice a week. Activity records showed that he has not been swimming for some time. Staff said this was because there are not always enough staff for 2 staff to take him, and also that some staff “won’t go swimming”. For example, on the afternoon of the inspection there were only 2 staff, so he could not go swimming. (See Staffing section of this report). He spent the whole afternoon sitting in a chair in the lounge, doing nothing. The television was on (but he has both visual and hearing impairments) and we did not see staff interacting with him at all. People are supported to go on holiday if they want to. One person had been to Devon for a week, and one to Norfolk. Two people flew to Turkey the day after our inspection. When we spoke to them they were very excited and really looking forward to their holiday. We saw that a new form has been introduced to record each person’s daily menu choices and activities. These are typed out and then staff are meant to record if the plan was carried out, or what the alternative was. We found that little had been recorded on the plan so we did not know whether or not an activity had taken place. There were also several entries of ‘choice of activity’. Occasionally there was a tick by this, but no information as to what the activity was. Staff told us that very little activity takes place in the house, other than the female staff giving the female resident a manicure. One member of staff does some cooking with the residents who are interested. An aromatherapist visits weekly and each person can choose to pay for a relaxing half-hour aromatherapy session with her. The advocacy service is working with the people who live at Woodlands, on a 2-year project called “Getting a New Life”. A ‘weekly shop’ is still done, on Saturdays, by 2 staff and one of the residents, for all the food and household items for all 4 people. Not only does this mean that the other 3 people don’t have the opportunity to go food shopping, no-one else can go out at this time because it leaves only 1 staff member in the home for the other 3 people. The manager and staff said that it is planned that in the future each person will write their own menu, do their own shopping and help with preparing and cooking the meal. The 2 people who have had their Woodlands DS0000071719.V377797.R01.S.doc Version 5.3 Page 15 rooms converted will cook and eat in their rooms, which will leave the main kitchen for the other 2 people to share. Although the kitchens have been in place for some time, none of this has started yet. Woodlands DS0000071719.V377797.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 People using the service experience adequate quality outcomes in this area. People’s personal care and healthcare needs are met, but medication is not handled safely enough. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The records, and our observations on the days of the inspection, indicate that people receive their personal care in the way they prefer. The ‘objects of reference’ could be used more successfully with the person who can’t see or hear so that this person can make more choices. Each person has a Health Action Plan (HAP) in place. These have been completed with information about each person’s health care needs. There is evidence that people see a complete range of healthcare specialists, for example for their ears, eyes, teeth, feet and so on, as well as doctors and Woodlands DS0000071719.V377797.R01.S.doc Version 5.3 Page 17 nurses when needed. However, the records are not completed consistently to show that appointments have been made/kept. For example an entry on one person’s file showed that the next ear care appointment was for June, but there was no record that this appointment had been kept. The manager looked in the daily notes which showed that the person did attend the clinic about their ears on that date. There was no date for a dental check “in one month” from the previous appointment: the manager found this in the diary. One person is prescribed a medication for epilepsy: none of the staff have been trained recently enough to administer this. The manager said this person has not needed this medication for a long time, and a procedure for calling 999 is in place. According to staff training records, the 7 staff (out of 15) who have had PEG feed training need a refresher course, and 8 staff have not done this training. One staff member we spoke with said s/he was trained by the manager, and then was observed carrying out this procedure until the manager considered s/he was competent. Staff have completed an ‘All About Me’ document which is part of the HAP. This is for the person to take with them if they have to go into hospital so that hospital staff will have useful information, such as how to communicate with the person and what their health is like. None of the people living at Woodlands are able to look after their own medication. Each person has their medication in a locked cabinet in their room, and staff administer their medication when they need it. Each person has a medication folder. The ones we looked at contained photographs and detailed guidelines about how the person likes to take their medication. We observed staff give one person his medication and the guidelines were followed. There were consent forms on the files showing that people consent to the staff administering their medication. There were guidelines in place for staff for administering ‘when needed’ medicines, and most of the Medication Administration Record (MAR) charts had been signed correctly. We noted that some of the ‘when needed’ medicines were missing from the new MAR charts. Staff explained that the pharmacist asks for these to be reordered every 2 months. Since the inspection we have discussed this with the CQC pharmacist and given his advice to the manager. On one person’s file we found a MAR chart that had been altered, and entries obliterated. Any alterations to MAR charts must be signed and dated, and altered so that the original entry can still be seen. On this file we also found that there had been a change in the person’s medication six days before our inspection. The person’s HAP, list of current medication in the care plan, and ‘All About Me’ documents had not been updated with this change. Woodlands DS0000071719.V377797.R01.S.doc Version 5.3 Page 18 A ‘stock sheet’ is in place so that a check can be kept on the number of tablets that are in the medicine cupboard. This was not accurate for one of the medicines we looked at. Woodlands DS0000071719.V377797.R01.S.doc Version 5.3 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 People using the service experience good quality outcomes in this area. People can be confident that their concerns will be listened to and acted on, and that staff know how to keep them safe from harm. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Woodlands has produced a good complaints leaflet, with pictures, symbols and easy language so that people know how to complain. However, the people who live at Woodlands would need a lot of support if they wanted to raise any concerns. An advocacy service works with people here. A complaints book is kept, which included one complaint since our last inspection. We discussed with the manager that there was too much confidential information for this complaint to have been entered into a book which anyone can look at. There was nothing recorded about any follow-up action: the manager said it had all gone to head office as it was about a member of staff who had since left. Staff support people to manage their money. A record is kept of every transaction and a system of sealed pouches is used for any cash. We checked one of these and the balance and cash were correct. We saw that these are Woodlands DS0000071719.V377797.R01.S.doc Version 5.3 Page 20 also checked during the provider’s monthly visit. We noticed that one person had paid out a lot of money for his activities (see Conduct and Management section of this report). In the office we were shown a file that contains Affinity Trust’s policy on Safeguarding Vulnerable Adults (SOVA), and the Luton and Bedfordshire SOVA policy and protocols: staff have signed to say they have read them. Staff we spoke with were clear about what to do if they suspect any abuse is happening, and training records showed that most of the staff have received SOVA training. According to the record, 3 staff need a refresher course, and one staff member has not done the training: the manager said this person was working on the bank (relief staff) so might have had the training. Woodlands DS0000071719.V377797.R01.S.doc Version 5.3 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 28, 29, 30 People using the service experience good quality outcomes in this area. Woodlands offers a comfortable, homely, clean and well-maintained home for the people who live here. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Having been completely rebuilt about 4 years ago, Woodlands is suitable for its purpose. Recently, kitchens have been fitted into the living areas attached to 2 of the bedrooms. This has been done so that in the future people can be more independent in their own ‘flat’. Each person has a hob, oven, fridge/freezer and kitchen sink, as well as a number of cupboards. They also have a small dining table and chairs, and a 2-seater settee. For one person this is fairly successful as he is mobile, but for the person in the wheelchair this Woodlands DS0000071719.V377797.R01.S.doc Version 5.3 Page 22 has not worked out so well. In the 2nd person’s living area, the room is quite dark and if anyone sat on the settee they would be looking at nothing but the kitchen units. Although there is a lowered work surface with space underneath for the wheelchair, he could not get to the sink to use it successfully, and the fridge/freezer is in the corner so he would have to squeeze past the table. The oven is too high up for someone in a wheelchair to use safely, and the oven door opens the wrong way even for someone able bodied and with good sight. Staff said that the cooker in the other person’s kitchen has not worked since it was fitted. On the day we visited, the home was clean and fresh, and comfortably furnished. People had chosen the colours they wanted their room painted, and they had been supported to put personal items of their choice in the rooms. The large dining table in the kitchen/diner is a popular place for some people to sit so they can chat to staff while they’re busy in the kitchen. New flooring has been laid where the new kitchen/dining areas have been created, and the carpet throughout the main corridor has been cleaned. Woodlands DS0000071719.V377797.R01.S.doc Version 5.3 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 People using the service experience adequate quality outcomes in this area. Staff are recruited and supervised well but there are not always enough staff on duty to make sure the people who live at Woodlands can lead full, interesting lives. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager said that staffing levels have improved and he is now happy with the level of staff. However, the rota showed that there had been a number of occasions in the 2 weeks before our inspection when the number of staff on duty did not meet the level the manager said should be on duty. The rota was not accurate. As well as the rota, staff sign the daily report and write down the hours they work: the 2 documents showed different information (see Conduct and Management section of this report). Nevertheless, from the records, our observations and the evidence on the day of the inspection, there are not always enough staff on duty to meet the needs of the people who live Woodlands DS0000071719.V377797.R01.S.doc Version 5.3 Page 24 here. One of the staff who returned our survey wrote “Not always enough staff on shift to support all the needs of supported persons to attend activities they have chosen”, and another wrote “More staff” when asked what the home could do better. Ensuring there are enough staff on duty was a requirement following our last inspection. Affinity Trust have a pool of bank staff who cover leave and sickness. The manager said that occasionally there are no bank staff to cover as the pool is not big enough for all the Affinity Trust services in the area. On the day of the inspection there were 4 staff on duty in the morning and some people went out for activities. However, 2 of the staff went home at 14:30 and no other staff came on duty, so there were only 2 staff. This meant that the planned activities for the afternoon, including one person going swimming, did not happen. We were told that a new member of staff had rung to say he could not work (which had also happened on the previous Saturday). When we discussed this with the manager on the 2nd day he said he had made arrangements for the shifts to be covered, so that all the activities could still take place. He was not aware that the staff had gone at 14:30 (both should have stayed later) nor that the activities had not happened. When we checked the rotas we found that swimming had been cancelled on other occasions recently. Staff told us that sometimes this is not because there are not enough staff, but not all staff are happy to go swimming, so it depends which staff are on duty. We looked at the documents the home has to have in place before new staff can start work, for 3 staff members. There was evidence to show that all the necessary checks had been done, for example a Criminal Record Bureau (CRB) disclosure, POVA check, and 2 references. There was proof of identification and a photograph on the files, as well as full employment histories and declarations by each staff member about criminal convictions and about their health. Information about the bank staff is kept at the organisation’s head office, but a pro-forma is in place at the home showing that all the necessary information has been seen. The manager told us he had no information about the aromatherapist who gives aromatherapy sessions to all 4 people, once a week. He explained that this therapist had been coming to the home before he started working there. Nevertheless, regulation 19 of the Care Homes Regulations also applies to anyone who works at the home, even if they are not employed by the provider. The regulation is very clear that the provider must carry out a CRB check and must obtain confirmation from the person’s employer that all the required information has been obtained. The personnel files we looked at showed that these 3 staff have undergone a full induction programme. One staff member we spoke with said “My induction Woodlands DS0000071719.V377797.R01.S.doc Version 5.3 Page 25 was very good and training is excellent – I’ve done loads of training”. Training records showed that a number of training courses have been held, and all 14 staff are up to date with training in medication and food safety. 13 staff have had training in first aid (2 of them need an update); and 10 staff are up to date with SOVA training. 11 staff had training in fire safety in August or September 2009, and the new staff have covered fire safety awareness in their induction, so only 1 staff member is not up to date with this training (see Conduct and Management section of this report). However, only 5 staff are up to date with infection control training; and only 5 staff are up to date with moving and handling training. None of the staff are up to date in administration of a medicine to control epileptic seizures, and none are up to date in PEG feed training (see Personal and Healthcare section of this report). Records indicated that some staff have had the opportunity to go on other training, such as health and safety; understanding risk assessments; understanding autism; understanding challenging behaviour; and report writing. From the AQAA we know that 4 of the 13 staff have been awarded a National Vocational Qualification (NVQ) in care. This is not a high enough percentage. The manager told us that he is about half way through NVQ level 4 and the deputy manager has completed NVQ level 4. One staff member said s/he has asked to do NVQ level 3 but “the company is saying no”. Records, and our discussions with staff, confirmed that staff have regular supervision sessions and all have a Personal Development Plan. Team meetings are held monthly. There was no system in place for ensuring that the bank staff receive supervision. Woodlands DS0000071719.V377797.R01.S.doc Version 5.3 Page 26 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41, 42 People using the service experience adequate quality outcomes in this area. Woodlands is not managed well enough to make sure that people have the best possible quality of life. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager has been registered with the Commission since October 2008. He told us that he is about half way through the NVQ level 4 Leadership and Management course. One of the staff we spoke with said “Naguib is a very Woodlands DS0000071719.V377797.R01.S.doc Version 5.3 Page 27 supportive manager; everything is going smoothly, it’s all in order and all information is available”. 4 of the 6 requirements we made following last year’s inspection have been met. However, we are disappointed that some of the areas we looked at (as discussed in other sections of this report) are not as good as we found them last time, 2 of the requirements we made have not been met, and the manager seemed unaware of some of the issues we raised. For example, we noticed that one person had paid out a lot of money for his activities (see Lifestyle section of this report). When we compared the records, we found that he had paid for every activity he had undertaken in the 3 weeks before the inspection: his contract states that “cost of social activities” is included in the fees he pays. We also found that he had paid for some of the equipment for his new kitchen, for example, the microwave, a jug and scales. The manager could not explain this. Following the inspection we discussed this with the funding authority and the provider. Although we did not make it a requirement, in last year’s report we wrote, “The staff rota was not an accurate record of which staff had been on duty. There were three records which all had to be read together to get an accurate picture. This is not satisfactory”. The staff rota was still not accurate at this inspection. Staff have not received adequate training in 2 of the mandatory topics relating to health and safety: moving and handling, and infection control. Moving and handling training is essential, especially as 2 of the people who live here use a wheelchair all the time and need assistance with all transfers and with all aspects of their daily lives. Last time, we required the manager to contact the fire authority to find out the level of training the authority advises for staff in this home: the manager admitted he had not done this. Most of the staff had attended fire safety training recently, but the manager still does not know when this needs to be repeated. The fire log shows that weekly tests of the fire alarm and emergency lighting systems are carried out. Adequate risk assessments had not been carried out for the risks that the 2 people going on holiday to Turkey might encounter. The manager had not realised that he should obtain personnel information about the aromatherapist who visits, to make sure there is no risk to the people who live at Woodlands. Affinity Trust has a number of ways to check that the home is offering a good quality service. Their quality assurance includes sending surveys to people involved with the home on a regular basis. Surveys had gone out to the people who live at Woodlands, professionals involved with the home, and staff, in September 2009, and to relatives in February 2009. There were a number Woodlands DS0000071719.V377797.R01.S.doc Version 5.3 Page 28 of positive comments from relatives: responses to the September surveys were still being returned. A representative of Affinity Trust has visited Woodlands each month and carried out a thorough ‘inspection’ of a number of aspects of the service. The reports of these visits (except for the August 2009 visit) were available for inspection. These reports include a number of actions for the manager to complete. A ‘traffic-light’ system, plus blue for excellent, is used to let the home know how well they are doing. Woodlands achieved excellent at the last visit. Woodlands DS0000071719.V377797.R01.S.doc Version 5.3 Page 29 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 2 2 3 3 3 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 2 27 X 28 3 29 3 30 4 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 3 LIFESTYLES Standard No Score 11 2 12 2 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 3 3 X 2 2 X Version 5.3 Page 30 Woodlands DS0000071719.V377797.R01.S.doc Are there any outstanding requirements from the last inspection? Yes 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 YA9 Regulation 13 Requirement Evidence must be available to show that any risks to people’s safety have been assessed and guidelines put in place to minimise the risks. So that people can be supported to take responsible risks. The amount and range of activities offered to people who live at Woodlands must increase, so that people have fulfilling lives. Medication must be handled and recorded correctly, so that people’s health is maintained and they are kept safe. There must be a sufficient number of staff on duty at all times to meet the needs of the people who live at the home. This requirement is repeated – timescale of 31/10/08 not met. Information as required by regulation 19 must be obtained for anyone who works at the home. So that people who live DS0000071719.V377797.R01.S.doc Timescale for action 31/10/09 2 YA12 16 31/10/09 3 YA20 13 31/10/09 4 YA33 18(1)(a) 31/10/09 5 YA34 19 15/11/09 Woodlands Version 5.3 Page 31 here are protected from abuse. 6 YA35 18 Staff must receive training in topics relevant to the work they do to enable them to do their jobs properly and keep people they support safe. For example, all staff who support one person with PEG feeding must receive training from an appropriate person; staff must receive training in supporting people who have sensory impairments and multiple disabilities. Records required by regulation must be accurate. The staff rota must accurately reflect the staffing in the home. Staff must be trained in all aspects of health and safety: all staff whose training is not up to date must undergo training in moving and handling and infection control. 31/12/09 7 YA41 17 31/10/09 8 YA42 13 31/12/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations Support/care plans should be developed further to include people’s hopes and aspirations, with goals set out and evaluated so that they can work towards their hopes. Woodlands DS0000071719.V377797.R01.S.doc Version 5.3 Page 32 Care Quality Commission Eastern Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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