Inspection on 05/01/07 for Woodlands

This inspection was carried out on 5th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodlands 17/10/07

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 Unannounced Inspection 5th January 2007 12:45 Woodlands DS0000063026.V303896.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.V303896.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.V303896.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Address Blundell Avenue Freshfield Formby Merseyside L37 1PH 01704 872132 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 Frances Taylor Foundation Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Woodlands DS0000063026.V303896.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th November 2005 Brief Description of the Service: Woodlands 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 home provides aids and adaptations to accommodate 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 owned and operated by the Francis Taylor Foundation, a national organisation who provide services to people with a variety of support needs. The home 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 administrative support. Most of the bedrooms are single rooms, where two people share, there are screens provided for privacy. Where needed all Service Users have 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 seating areas, bathrooms and a small kitchen within the home and a small, private, courtyard outside. The home has operated for many years as part of a larger care home registered as St Josephs Adult Services. In June 2005 the three units within this service were separately registered as part of the organisations aim to modernise the service. Woodlands DS0000063026.V303896.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two CSCI Inspectors, Lorraine Farrar and Diane Sharrock carried out the site visit. Information for the inspection was gathered in a number of different ways. This included an unannounced site visit where time was spent reading records and looking at the building. ‘Case tracking’ was used as part of the visit. This involves looking at the support a person gets from the home including their care plans, medication, money and bedroom, time is also spent meeting with the Service User 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. Comment cards were sent out before the inspection. 3 had been completed by Service Users with help from Staff in the home. The Manager also contributed to the inspection by completing a questionnaire. The information gathered from the sit visit along with any information about the home, that the CSCI has received since the last key inspection, has been used to write this report. Fees for living in the home are £924 per week. What the service does well: The majority of care plans in the home are updated regularly and provide a good basis for Staff to support Service Users and meet their personal and healthcare needs. Staff spoken with were able to explain their role in supporting Service Users and how they meet peoples support needs. Service User are supported to attend an on- site Resource Centre and to use the in house hydrotherapy pool. Support is also provided to Service Users to get out and about in the local community and to visit their family. Family and friend are welcomed to the home and visit frequently The home is clean throughout with equipment provided to meet Service Users needs and bedrooms areas in particular personalised and decorated to a high standard. Staff receive training in basic care practices and in areas of health and safety. This helps to ensure that they can meet most Service Users basic needs. Staff spoken with were enthusiastic about their role and stated that they looked forward to further improvements within the home. Woodlands DS0000063026.V303896.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 DS0000063026.V303896.R01.S.doc Version 5.2 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 DS0000063026.V303896.R01.S.doc Version 5.2 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): 2 The quality in this outcome area is poor. This judgement has been made using available evidence, including a visit to this service. Sufficient information is not always obtained about a new Service User, to ensure that the home can meet all of the person’s needs and choices EVIDENCE: The home has a policy in place for admitting a new Service User. This includes carrying out a full assessment of their needs to make sure that Staff and the environment are able to support the person effectively. A Service User who had been recently admitted had not had a new assessment of their needs carried out either before or shortly after they had moved in. Information from 2004 was on file, from a previous occasion when the person had stayed at another home on site, however this had not been updated. In discussion with the person and with Staff it was evident that the person communicates using sign language. This had not been clearly identified on the assessment and Staff in the home did not have the skills to use this form of communication. In not identifying the person’s communication needs the home had not identified that they were unable to fully communicate with the person, and therefore may not be able to meet their needs and choices fully, without further training for Staff. Woodlands DS0000063026.V303896.R01.S.doc Version 5.2 Page 9 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 & 9 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Service Users individual needs and choices are generally but not always identified and met within the home EVIDENCE: All Service Users have an individual care plan in place. Three of which were read as part of the site visit. The content and way in which plans were written varied. Two of the plans were up to date and had been regularly reviewed with input from the person’s relatives and other professionals involved in their care. Regular assessments of the person’s healthcare needs had been carried out and clear, written guidelines were in place for meeting these needs. However Plans are not always written in a way, which is respectful of Service Users, with use of words such as ‘nappy’ being written in one care plan. The third plan was for a Service User who had been admitted a couple of months previously but had used the Francis Taylor Organisations, services in the past. This plan contained information about supporting the person with their healthcare and a pen picture that had not been updated since 2004. Woodlands DS0000063026.V303896.R01.S.doc Version 5.2 Page 10 No plan was in place stating how Staff should meet the person’s communication needs. This lack of up-to-date information may mean that all of the person’s current health and personal care needs are not identified and met. In not identifying the way in which the person communicates, the home were failing to make sure that Staff had the skills to communicate effectively with her. Not all of the people living at Woodlands use verbal forms of communication. Care plans provide some information on the person’s likes and dislikes and non-verbal communication. One plan stated that the person likes ‘to look smart’ and to listen to music. In meeting with the person it was evident that Staff had supported him in accordance with these preferences. Many of the Service Users have support from their families in making decisions and a letter on file from Staff to the organisation advocated strongly for one Service User to have their own room rather than a shared room. This had a positive effect for the Service User who had recently moved into a single bedroom. However a new Service User had recently moved into a shared room. There was no evidence that the views of the person living in this room had been taken into consideration. Although Staff felt the move had worked out, they also explained that there is a large age difference and they have to persuade one of the Service Users to play her music lower than she wants to, in order not to disturb the person she shares with. Staff spoken with were able to given some examples of how Service Users make decisions. For example one Service User has decided she would like to have a bath daily and Staff provide support with this. However Staff also felt that many of the Service Users were unable to make decisions, with one explaining, “just 3 communicate, the rest can’t really communicate their needs.” Another member of Staff felt that only one Service User was able to make any decisions. Care plans should contain a section, which clearly identifies the choices, and decisions the person can make and how Staff can support them with this. Up to date risk assessments were in place in two of the care plans and these had been regularly updated. However in the third plan risk assessments had not been updated since 2004. Therefore any new or changed risks for the person may not be recognised and acted upon. Woodlands DS0000063026.V303896.R01.S.doc Version 5.2 Page 11 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 quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Service Users lifestyle choices are not always identified and met within the home. EVIDENCE: Records showed that one Service User uses a recognised form of sign language know as Maketon. During the site visit the Service User demonstrated to the Inspector that she was able to communicate using this form of sign language. However none of the Staff working that day were able to use this form of communication, with one member of Staff explaining that it was mainly the Service Users family who used sign language with her. In not being skilled in using the form of communication a Service User is familiar with, the home are failing to make sure that the person develops their skills and is fully supported to make their choices and opinions known. One Service User explained that she had enjoyed a holiday to Blackpool and regularly enjoys trips out with Staff. She also explained that she enjoyed the Christmas festivities, including a party arranged in the home. Staff explained Woodlands DS0000063026.V303896.R01.S.doc Version 5.2 Page 12 that Service Users are supported to go on holiday each year, and that some of their families also went on the holiday in Blackpool. During the week all Service Users attend the on –site Resource Centre 3-4 days per week. On the days they do not go they are supported by Staff in the home. A member of Staff explained that Staff carry out housekeeping tasks in an afternoon but also try to spend time with Service Users. During the site visit Staff explained that they had intended to go out with Service Users but had cancelled this until the following day. Three Service Users were sitting in an open sitting area in the hallway from lunchtime until other Service Users returned at 4pm. For the majority of this time they sat watching a video with little or no input from Staff. The area felt cold and Staff eventually brought blankets to cover Service Users and sat and chatted with them for a while. Records in the home showed that Service Users receive some support with leisure activities, this includes, using the on site Resource Centre and hydrotherapy pool, going out to the theatre, for meals and bus trips. Records also showed that Service Users visitors are welcomed at any time and that the home supports Service Users to see their families whenever possible. There is now a choice of two meals for Service Users at lunch and tea times, although no record of what these choices are, was available in the home. Staff advised that there is enough of each option provided for Service Users to have a choice. Individual menu records are kept for each Service User, these showed that people are offered a choice of meals and that any special dietary needs they have are catered for. The evening meal is served in the dining room. This room is very basic in appearance, with no condiments, menus or tablecloths in place and tables not laid or looking inviting. Everyone who needed support with their meal was provided with this, however the way in which it was provided varied. One Service User was supported by a member of Staff who sat next to her and quietly assisted her. However another Service User was supported by a member of Staff who stood over her, mixing her food up with a spoon. Good practice was seen in that one Service User was offered a choice of meals, using non-verbal communication. However a member of Staff approached another Service User and put an apron over her head without explaining what was happening to her. One Service User who had a soft diet was served her meal all mixed together. This resulted in it appearing uninviting and would not provide the full taste of the contents for her. Staff explained that they used to liquidise the meal separately, however their liquidiser had broken and it was now sent from the main kitchen ready prepared. Staff had not taken any action to replace the liquidiser or to instruct kitchen Staff on the correct way to serve soft diets. Woodlands DS0000063026.V303896.R01.S.doc Version 5.2 Page 13 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 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Service Users health and personal care needs are usually identified and met by Staff within the home. EVIDENCE: Care plans and the homes daily diary evidenced that Staff work with other health professionals to identify and meet Service Users health and personal care needs. In two of the three care plans read there were clear assessments, information and guidelines about how to meet the person’s health care needs and prevent health problems from arising. Good practice was evident in that photographs were used to explain exactly how to position one Service User when they are having bedrest. In discussions with Staff they were aware of and able to explain how they follow plans to meet individuals support needs. In the third plan some health care information was up to date and had been reviewed regularly. Other information had not been updated since 2004 and therefore may not be up to date. Woodlands DS0000063026.V303896.R01.S.doc Version 5.2 Page 14 One plan contained clear information about supporting the person with their medication, including the use of ‘as required’ medication. The home has a separate room for the storage of medication, this room was clean with medication correctly stored and recorded. None of the people living in the home currently take controlled medications. However there is no safe storage or book, provided for these drugs if they were prescribed. Records of drugs given to Service Users were completed on their medication sheet. One Service User had not used their ‘as required’ medication since July 06, however she was given this for 5 days over the Christmas period. Although signed for on her medication sheet, no consistent record of the reasons why it had been given or assessment of why it was needed for a period of time had been recorded in her daily records. When an ‘as required’ medication is given to a Service User clear records of the reasons why, along with an assessment of the time it is used for should be recorded. This will help Staff and medical personal to ensure the medication is used correctly and is effective. A weekly audit of medications in the home is carried out. This did not include checking medications held in the fridge or for return. These items should be added to the weekly audit in order to ensure that out of date medications or medications no longer needed, are not stored for periods of time. Woodlands DS0000063026.V303896.R01.S.doc Version 5.2 Page 15 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 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Clear polices and procedures are in place to protect Service Users however these need to be further developed to protect Service Users monies. EVIDENCE: The home has a complaints procedure, which tells people how to make a complaint and how it will be investigated. Information about this is in the Service Users Guide and at the front door of the home. The complaints procedure is also available to Service Users in an easy to understand picture format. Information about the local authority’s adult protection procedures is available in the home and Staff have received training in this area. Money held for three people in the home was looked at. This tallied with the records kept by the home. However on occasion Staff take Service Users money with them to spend and it may be several days before this is returned. In addition no clear audit or checking system of good purchased is in place. The practice of Staff taking money out of the home without the Service Users and it not being returned swiftly, along with no clear check of goods purchased, means that there is no clear audit trail in place and no protection for either the Service User or Staff. Woodlands DS0000063026.V303896.R01.S.doc Version 5.2 Page 16 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 & 30 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Service Users have a safe, clean environment to live in, however shared areas would benefit from refurbishment and redecoration. EVIDENCE: All areas of the home were clean and tidy, however during the afternoon the home felt cool and Staff provided blankets for Service Users who were in the open sitting area of the hallway. No thermometer was available to check the temperature of the home, however Staff advised that they ‘think’ the heating goes off during the day and radiators were cool to the touch. As many of the people living in the home have physical disabilities and are unable to move around very much, it is likely that they will feel the cold, therefore temperatures need to be maintained at a comfortable level for them. The appearance of the environment is varied. Service Users bedrooms and toilets are highly personalised, reflecting where possible their choices, personalities and needs. Similarly one of the small lounges was nicely decorated and had leather armchairs. These rooms had been furnished, and in the case of bedrooms, decorated with Service Users money. Communal areas were maintained and decorated to a lesser standard. One small lounge had Woodlands DS0000063026.V303896.R01.S.doc Version 5.2 Page 17 decor which appeared tired and mis-matched chairs. Shared bathrooms appeared basic with an institutional appearance and the dining room was an uninviting place to share a meal in. Staff advised that they have prepared and put in a bid to the organisation to have all communal areas redecorated and some re-carpeted. There is a separate laundry room, which was clean and well organised in order to prevent any cross infection. Woodlands DS0000063026.V303896.R01.S.doc Version 5.2 Page 18 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): 32,34 & 35 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Staff are experienced in meeting Service Users basic needs but need to further develop their skills to work in partnership with Service Users. EVIDENCE: Through discussion with Staff it was evident that they have had a variety of training to meet Service Users basic needs. This was varied and included, attitudes and values, use of the hydrotherapy pool, moving and handling and attitudes and terminology. All Staff undergo induction training and work towards obtaining a qualification in Learning Disabilities (LADAFF). In addition to this the home provides an assessor for Staff working towards a care qualification (NVQ). Four of the 14 care Staff have obtained this and another four are working towards it. Staff spoken with were enthusiastic about their role and the support they provide, explaining that they really enjoy their job and feel the home is improving. They were able to explain the care and support they provide to individuals. However several of the Staff spoken with were unable to explain how people living in the home, who did not verbally communicate, were able to make decisions. They occasionally used words that would be more suited to working with children; this included the use of ‘nappy’ and ‘cot sides’. Woodlands DS0000063026.V303896.R01.S.doc Version 5.2 Page 19 One Service User has a stomach tube fitted, which is used to give them fluids. Care Staff explained that Nurses in the home had shown them how to use this and records on the persons file contained a list of Staff who had been shown this procedure. No records of the actual training provided, including information about infection control and an assessment of Staff competency was on file. Without a written training plan and regular assessments of competency the Service User may not receive the correct support with this procedure. Staff files were looked at for four members of Staff. All contained copies of the persons application form, notes on their interview, written references and evidence that police checks had been carried out. These checks help the home to make sure that all Staff are suitable to work with vulnerable people. Not all files contained a photograph of the member of Staff for identification purposes. Woodlands DS0000063026.V303896.R01.S.doc Version 5.2 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): 37,39 & 42 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The home is operated by an experienced manager, internal checks on the quality of the service are not always focused on the experiences of the people living there. EVIDENCE: The home does not currently have a registered manager. The site visit was carried out with Mrs Diane Ellis who was acting Manager. Since then she has been successful in her application to become appointed Manager for the home. Mrs Ellis holds a Registered Mental Nurse qualification and has undertaken training in leading disabilities. She has several years experience of management within a care setting for young adults. A yearly audit of the service is carried out by the organisation. This was last carried out on Woodlands and identified that the home was largely meeting national care standards for younger adults. In addition regular monthly visits are made to the home by the organisation to look at the quality of the service. Woodlands DS0000063026.V303896.R01.S.doc Version 5.2 Page 21 However there was little evidence available that this audit had used observation of life in the home or looked at outcomes for the people living there, in reaching this decision. The organisation should look at systems for establishing the experiences of life in the home for Service Users, they can then use the outcome of this to plan for improvements to the service. Up to date health and safety checks had been carried out for the hot water, gas and electrics. Testing of small electrical appliances was due in December 06 and had not been carried out. Records showed that regular fire tests had been carried out, however emergency lights had not been tested since October 06 and neither a fire drill or check of escape routes had taken place since May 06. Not carrying out regular checks of health and safety procedures and equipment may place Service Users, Staff and visitors at risk. Woodlands DS0000063026.V303896.R01.S.doc Version 5.2 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 X 2 1 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 2 12 3 13 3 14 2 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 2 X X 2 X Woodlands DS0000063026.V303896.R01.S.doc Version 5.2 Page 23 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 YA2 Regulation 14 Requirement The Registered Person must ensure that no Service User is admitted to the home without a full assessment of their needs being carried out. This will ensure that the assessment identifies whether the home is suitable to meet the person’s needs. The Registered Person must ensure the care plan identified at inspection is up to date and accurate. This will ensure that all of the person’s needs and choices are identified and how they are to be met. The Registered Person must ensure that where ‘as required’ medication’ is given a record of the reasons for this decision is recorded. Timescale for action 28/02/07 2 YA6 15 (1) 15(2)(b) 28/02/07 3 OP9 13(2) 28/02/07 4 YA23 13(6) The Responsible Person must 07/04/07 review arrangements for handling Service Users money in the home. This will ensure Service Users are fully protected. Woodlands DS0000063026.V303896.R01.S.doc Version 5.2 Page 24 5 YA24 23(2)(p) 6 YA35 18(1)(c)(i) 7 YA35 18(1)(a) The Registered Person must monitor room temperatures within the home and take swift action if they are at a level not comfortable for Service Users. The Registered Person must provide a training programme for all Staff who support a Service User with their Peg. This will ensure that Staff are competent to provide this support. The Registered Person must provide training for all Staff in the use of Makaton sign language. This will ensure that Staff are able to communicate effectively with people living in the home. The Registered Person must check all Staff files to ensure they contain identification, including photographs of Staff. 28/02/07 07/04/07 07/03/07 8 YA34 19(1)(b) 28/02/07 9 YA42 23(2)(c) The Registered Person must 28/02/07 ensure that small electrical appliances are checked at regular intervals. This will ensure the home is safe for people to live in. 28/02/07 10 YA42 23(4)(c)(e) The Registered Person must ensure that Staff participate in regular fire drills Fire escape routes are checked regularly Woodlands DS0000063026.V303896.R01.S.doc Version 5.2 Page 25 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 The Registered Person should formulate a policy for use of shared bedrooms. This will help to ensure that Service Users needs and wishes are taken into account when sharing a room. The Registered Person should include in all care plans a section identifying the decisions that the person can make and how Staff can support them with these. The Registered Person should provide a storage and recording system for controlled drugs. The Registered Person should provide a plan for upgrading communal areas within the home. The Registered Person should review their quality audit system to ensure it includes Service Users experiences of life in the home. 2 OP7 3 4 5 OP9 OP24 YA39 Woodlands DS0000063026.V303896.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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. 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