Inspection on 08/08/06 for Woodlands

This inspection was carried out on 8th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodlands 31/10/08

Woodlands 19/01/06

Woodlands 03/08/05

Woodlands 29/03/05

Woodlands 03/09/04

Woodlands 10/02/04

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

CARE HOME ADULTS 18-65 Woodlands 4 Gaskells End Tokers Green Reading Berkshire RG4 9EW Lead Inspector `Catherine Kane Unannounced Inspection 8th August 2006 17:30 Woodlands DS0000013218.V306843.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 DS0000013218.V306843.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 DS0000013218.V306843.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Address 4 Gaskells End Tokers Green Reading Berkshire RG4 9EW 0118 9724913 0118 9724913 haroon@caretech-uk.com 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) CareTech Community Services Limited Ms Katrina Player Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Woodlands DS0000013218.V306843.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th January 2006 Brief Description of the Service: Woodlands is a three-bedroomed detached house in a quiet cul-de-sac in a small village. It is registered for three people with a learning disability, although only two residents are currently accommodated at the home. CareTech is the provider organisation and is a national company providing accommodation with personal care to people with learning disabilities. The service provides long-term, rather than respite or emergency accommodation and Woodlands has been home to the current residents for many years. The home accesses local services for both health and social activities. The fees for this service are £1,355.55 per week. Woodlands DS0000013218.V306843.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 5.30pm on Tuesday, 8 August 2006. The inspector was in the service for three hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s owner or manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the services and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. The registered manager was on duty at the time of the inspection. The inspector also spoke with two staff on duty. The inpsector saw staff and residents who were preparing for their evening meal and saw how staff help residents look after and take their medicines. She also looked at residents’ care plans, staff files and other records kept in the home and made a tour of part of the premises. The inspector would like to thank the manager and her staff team for their assistance with the inspection. She also thanks residents and all others who shared their experience of this home. What the service does well: What has improved since the last inspection? Some improvements have been made in the garden. Woodlands DS0000013218.V306843.R01.S.doc Version 5.2 Page 6 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 DS0000013218.V306843.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 DS0000013218.V306843.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission procedure is good although not tested, as there have been no new admissions to the home. EVIDENCE: There have been no new admissions to this home since the last inspection. At the time of this inspection the home had one vacancy. The inspector and the manager discussed the importance of making sure that the home is the right place, the wishes of all the people who already live in the home are carefully considered and that the staff team have the right skills and systems in place before offering a place to any new resident. Generally, admissions would not be made to the home until a full needs assessment has been undertaken. The home would then be able to confirm that they can meet the needs of the individual through the service they deliver as detailed in the Statement of Purpose. Woodlands DS0000013218.V306843.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 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care planning system in place to provide staff with the information they need and for assessing risk is adequate. EVIDENCE: Both residents’ care records were viewed during the inspection and in each case the files had all the relevant information. The home uses a care planning system that promotes the use of charts and task checklists for staff. These were bulky and not easy to read. At the inspection held in January 2006 the inspector saw that a more person centred approach to care planning that took into account residents’ hopes and wishes was being introduced. However, there has been no further development or improvements in this area since what the inspector saw at the last inspection. The inspector recommends that introduction of this new person centred system be given priority. The home has a system for identifying and assessing risk for residents during everyday activities. These were seen to have been reviewed, signed and dated by the manager. Woodlands DS0000013218.V306843.R01.S.doc Version 5.2 Page 10 From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. Woodlands DS0000013218.V306843.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): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Opportunities for people who use this service to take part in a variety of interesting activities are adequate. EVIDENCE: On the day of the inspection the inspector was in the home during the late afternoon and evening. She spent this time with both residents and the staff on duty and went with residents and staff on a short outing after dinner. Neither resident was able to communicate clearly with the inspector but with the help of staff and notes seen during the inspection she got an idea about things they like to do, from reading notes kept in residents’ Social Diaries that indicated when and what activities took place. Both residents have opportunities to get out and about in their local community. Woodlands DS0000013218.V306843.R01.S.doc Version 5.2 Page 12 At the last inspection residents had been involved in planning their annual short break holiday. Staff told the inspector that plans for this holiday had been cancelled. They were unclear why this decision had been made. The inspector was in the home while residents were having their evening meal. Regular drinks and snacks are available. A varied menu is provided and residents’ special dietary needs are catered for. Woodlands DS0000013218.V306843.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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The personal and healthcare needs of residents are generally well met. EVIDENCE: Essential information needed by staff to be able to provide personal and health care support was included in residents’ files. Staff help residents to look after their own medication and see they get to see their local GP and other community healthcare services when needed. The inspector saw how the home helped residents to access specialist healthcare support when this was needed. This was well recorded by staff in the resident’s notes. A comment card was returned from the GP involved in the healthcare of residents who live in this home. They indicated that they were satisfied with the overall care provided in this home. Residents’ medicines are securely kept in a locked medicines cabinet. The home uses a pharmacist produced medication administration record (MAR). Records were kept of staff assessed as competent to administer residents’ Woodlands DS0000013218.V306843.R01.S.doc Version 5.2 Page 14 medicines. During the inspection two staff members confidently demonstrated how a resident’s medicines are looked after and how residents are helped to take their medicines. The inspector recommends that the home should keep a sample of the initials of staff who are assessed as competent to administer residents’ medicines. The inspector recommends that the home should retain patient information leaflets or up to date information relating to residents’ medicines. Woodlands DS0000013218.V306843.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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a clear protection from abuse policy and the complaints procedure is good. EVIDENCE: The manager provided the inspector with information on how the organisation was responding to a complaint raised by a neighbour. This was in line with their complaints policy. The Commission has received no information relating to complaints since the last inspection. Staff have attended specific training on protecting vulnerable people from abuse and about local adult protection procedures in line with the Oxfordshire Multi-agency Codes of Practice. The Commission has received no information relating to adult protection issues in the last year. Woodlands DS0000013218.V306843.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 and 28 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was neat, tidy and clean at the time of the inspection. EVIDENCE: The home has been kept in a good state with a programme of maintenance and repair. Some improvements have been made in the garden. These include a new fence and seating area with pot plants. This was seen to be enjoyed by both residents. All areas of the home visited by the inspector were clean and tidy. Woodlands DS0000013218.V306843.R01.S.doc Version 5.2 Page 17 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 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home’s recruitment procedures and training for staff to do their jobs well are good. EVIDENCE: During the inspection the inspector spoke with two staff. Staff commented that morale is ‘not bad’. One member of staff has left, two other staff have transferred to other CareTech homes and one staff member has been transferred to this home from another CareTech service since the last inspection. The recruitment process is thorough. The home keeps a record of training completed by staff; staff spoken with confirmed details of the training they have undertaken. A senior CSCI manager has undertaken an audit of Criminal Records Bureau (CRB) disclosures made on staff and stored at the CareTech head office. The following recommendations were made. Woodlands DS0000013218.V306843.R01.S.doc Version 5.2 Page 18 All CRBs with a criminal record should be reviewed by one person who is a senior manager within CareTech. All staff with a CRB showing a criminal record must have a query sheet. The query sheet or other form should provide greater detail as to the evidence, risk assessment and reasons for the decision to appoint or not. As is the case, Protection of Vulnerable Adults (POVA) First should only be used when the risk not to do so is serious for the service users. However, any person appointed under POVA First should be asked to sign that they do not have a criminal record over and above their answers within their application forms. The manager provided details of the range of training opportunities to enable staff to do their job. Woodlands DS0000013218.V306843.R01.S.doc Version 5.2 Page 19 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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has returned to post following an absence of several months. It is expected that the registered manager shall undertake further training qualifications at level 4 NVQ in both management and care. Therefore this standard is rated as ‘standard almost met’ scored 2. The registered manager has the necessary experience to run the home. She is aware of and works to the basic processes set out in the National Minimum Standards. The manager has developed systems that monitor practice and compliance with the home’s plans, policies and procedures. Action taken to respond satisfactorily to requirements and recommendations from the last inspections has been adequate. The home has sound policies and procedures in line with current thinking and practice. Efficient systems are in place to monitor staff adherence to policies Woodlands DS0000013218.V306843.R01.S.doc Version 5.2 Page 20 and procedures during their practice. The home works to a clear health and safety policy and checks take place to ensure the home meets relevant health and safety requirements and legislation. Records kept were generally adequate and are routinely completed. The inspector has received copies of the proprietors’ representative’s monthly visit reports. Until further notice, the home is no longer required to send these to CSCI but is to keep a copy in the home available for inspection. CareTech, who run this service, has financial and accounting systems subject to internal and external audits. Woodlands DS0000013218.V306843.R01.S.doc Version 5.2 Page 21 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 3 25 X 26 X 27 X 28 3 29 X 30 X 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 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 3 X Woodlands DS0000013218.V306843.R01.S.doc Version 5.2 Page 22 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA14 Regulation 12(2) Requirement The responsible person must provide details of how and by whom the decision was made for residents not to have an annual holiday. Timescale for action 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations The inspector recommends that introduction of a person centred care planning system be given priority. The inspector recommends that residents’ care plans and other record keeping systems used in the home should be reviewed to make written information easier to read. The further development of the person centred care plans should be completed in a timely fashion. This was recommended at the inspection of 19/20 January 2006. The inspector recommends that the home should keep a sample of the initials of staff who are assessed as competent to administer residents’ medicines. The inspector recommends that the home should retain patient information leaflets or up to date information DS0000013218.V306843.R01.S.doc Version 5.2 Page 23 2 3. YA20 YA20 Woodlands 4. YA34 relating to residents’ medicines. All CRBs with a criminal record should be reviewed by one person who is a senior manager within CareTech. All staff with a CRB showing a criminal record must have a query sheet. The query sheet or other form should provide greater detail as to the evidence, risk assessment and reasons for the decision to appoint or not. As is the case POVA First should only be used when the risk not to do so is serious for the service users. However any person appointed under POVA First should be asked to sign that they do not have a criminal record over and above their answers within their application forms. Woodlands DS0000013218.V306843.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South, Cowley Oxford OX4 2SU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Woodlands DS0000013218.V306843.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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