Inspection on 01/12/05 for Woodlands Care Home

This inspection was carried out on 1st December 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Woodlands Care Home 20/02/08

Woodlands Care Home 25/09/06

Woodlands Care Home 18/07/05

Woodlands Care Home 09/02/05

Woodlands Care Home 20/12/04

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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 Care Home 375 Woodlands Road Netley Marsh Totton Hampshire SO40 7GB Lead Inspector Eamonn Kelly Unannounced Inspection 1st December 2005 1:00pm Woodlands Care Home DS0000055845.V268943.R01.S.doc Version 5.0 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 Care Home DS0000055845.V268943.R01.S.doc Version 5.0 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 Care Home DS0000055845.V268943.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Woodlands Care Home Address 375 Woodlands Road Netley Marsh Totton Hampshire SO40 7GB 023 80 871704 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) Truecare Group Limited Miss Danniella Kirsty Andre Care Home 6 Category(ies) of Learning disability (6), Mental disorder, registration, with number excluding learning disability or dementia (6) of places Woodlands Care Home DS0000055845.V268943.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users may only be admitted in the MD category if they also have a learning disability. Service users may only be accommodated between 18 and 64 years of age. 18th July 2005 Date of last inspection Brief Description of the Service: Woodlands Care home is registered to provide personal care and accommodation for up to six people with learning difficulty and associated mental health disorder. Currently, all service users are female. The home is located in the village of Netley Marsh, close to the local shops and pub. The home is a large detached property with bedrooms on the first floor and communal areas on the ground floor. All bedrooms are for single occupancy and have en-suite shower facilities. Service users and members of staff share a large lounge/dining area with adjoining conservatory, leading to an enclosed garden. The home has a large kitchen and separate laundry room. Woodlands Care Home DS0000055845.V268943.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection (unannounced, between approx 01.00 - 05.30 pm) consisted of meeting with the manager (Dannee Andree) and acting manager (Matthew Thomas), members of staff and residents. One visitor was met. All bedrooms and communal areas were inspected. Some of the home’s policy and procedure statements/guidelines were checked. Some care plan records were inspected. What the service does well: What has improved since the last inspection? The manager and acting manager demonstrated how they carry out continuous reviews and improvements as a form of quality assurance. These developments included • • • Addition of a “restrictions rationale” to care plan records. Refreshed format for recording care needs and meeting needs. Review of how service user’s personal development should be improved. Woodlands Care Home DS0000055845.V268943.R01.S.doc Version 5.0 Page 6 The manager’s time is now fully allocated to management and supervisory duties. 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 Care Home DS0000055845.V268943.R01.S.doc Version 5.0 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 Care Home DS0000055845.V268943.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5. Prospective service user’s care needs are assessed in detail and they (and their supporters) receive advice and guidance in making a choice about taking up residence and subsequently in settling in. EVIDENCE: Admission of prospective service users is dependent on meeting conditions of registration. A detailed assessment procedure is undertaken to ensure as far as is practicable that the person is likely to benefit from the placement. Care managers and health professionals are involved in pre-admission assessments. At this stage care plan records are begun: this forms part of revised approaches to person centred planning. In the examples discussed, it was clear that prospective service users and their supporters receive good support at this important and difficult stage. A resident’s relative explained how this happened in one case. As a form of quality assurance, the acting manager is updating the service user’s guide as he feels it is time to refresh the current format and presentation. Each service user receives a personal contract that outlines the rights and responsibilities of both parties. Woodlands Care Home DS0000055845.V268943.R01.S.doc Version 5.0 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. Service user’s needs are met with the help of a person-centred planning and review process. This has been enhanced by the recent addition of a “restrictions rationale” that identifies issues requiring special attention by staff for each individual. EVIDENCE: Care plan records comprise a variety of information necessary for the day-today care and well being of residents and to enable identified needs to be met (with reviews to validate progress). These contained useful monthly evaluations of each service user’s condition and review reports. In the opinion of the acting manager, these records contributed positively to residents’ care: recent amendments are being made to make them more effective. In the examples seen, the evaluations were easy to read and appropriately informative. The manager and acting manager have given much thought to identifying necessary restrictions to residents’ personal freedoms. The “restrictions rationale” (that records the instances and reasons for any restrictions to freedoms) is regarded by members of staff as a useful tool in preventing or alleviating service user’s possible distress (or restriction of some freedoms) Woodlands Care Home DS0000055845.V268943.R01.S.doc Version 5.0 Page 10 that could lead to challenging behaviours. The previous inspection report stated that all members of staff received training in understanding the causes of challenging behaviours and working effectively with service users. Members of staff assist service users to make decisions about how to spend their time within and outside the home. This includes guidance and support on how to enjoy a variety of activities, how to dress appropriately, how to maintain personal relationships and how to deal with personal finances. Step by step progress is identified as well as reasons why progress may be limited in some instances. Woodlands Care Home DS0000055845.V268943.R01.S.doc Version 5.0 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 & 14. Service users have a programme of activities based on their individual abilities and aspirations. EVIDENCE: Two vehicles (including a 7-seater) are available for assisting service users and members of staff visit leisure centres and many other locations. On the day, some residents were at home, two had gone shopping with members of staff, one visited hospital (with a member of staff and a family member) and another had gone for an outing in a home’s vehicle. Some service users maintain charts of weekly activities. All receive support in deciding upon relevant pastimes and activities. Details of agreed programmes are contained in service user plans. Service users receive support in developing life skills. There is a high level of expertise at the home in communicating effectively with residents. Residents help in agreed and structured ways in the running of the home. Woodlands Care Home DS0000055845.V268943.R01.S.doc Version 5.0 Page 12 The previous inspection report referred to how service users receive support in developing and maintaining personal relationships and in overcoming actual and potential problems. The report also details aspects of food provision and preparation: some of these aspects were discussed in outline on this occasion. In the kitchen were detailed records of menus, food to be bought and catering for diabetic needs. The acting manager indicated that adequate food budgets are available to the home: he was confident that members of staff had the necessary skills to ensure that service users had good meals and food at all times. Some service users have specific support from a dietician. Woodlands Care Home DS0000055845.V268943.R01.S.doc Version 5.0 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. Service user’ healthcare and personal needs are met both by members of staff and healthcare specialists. EVIDENCE: The home has specific rules in place for cross gender personal care (all service users are female). Each has a single bedroom with en-suite (inc. shower). Personal care and advice about private relationships form an important part of person centred planning and care. Profiles of service users (discussed with the acting manager) revealed that service users benefited from the services of a psychologist, psychiatrist, dietician and others (GP, dentist, chiropodist and optician). A specific current issue discussed related to dental care (a dentist with special expertise in working with people with learning disabilities is associated with this service). Service users with diabetes receive attention from a chiropodist. Medication is securely stored with medication administration record (MAR) sheets maintained accurately. [It was agreed that the CSCI pharmacist does not need to review the medication process because of good storage of medications, good recording of each part of the process and attendance by all staff who administer medication on “accredited” training]. Where a service user could maintain her medication, assistance and supervision is provided (as Woodlands Care Home DS0000055845.V268943.R01.S.doc Version 5.0 Page 14 currently happens). The acting manager stated that “as needed” medication must always be authorised by a manager. Woodlands Care Home DS0000055845.V268943.R01.S.doc Version 5.0 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 views of service users and their supporters are listened to and there is reflection on this. Service users are in a safe environment. EVIDENCE: The acting manager stated that he was confident all members of staff understood local authority policies and procedures for adult protection: they have received training on this. As a quality assurance measure, he is replacing the displayed complaints leaflet with a more straightforward version that also includes the Commission’s phone number (this together with the more detailed complaints procedure will be contained as an appendix in the revised service user’s guide). The home has a record of complaints made together with the outcome of assessments and investigation. The home has tightened up on procedures for looking after service user’s monies: this includes new auditing procedures for monies at the end of each shift. Service users general safety is protected through the use of detailed recruitment procedures (application forms/taking up of references, CRB/POVA first checks, induction, probation, supervision). These procedures have been reviewed by the manager and acting manager (to re-assess for continuing robustness). Profiles of service users discussed with the acting manager revealed that members of staff have a good knowledge of service user’s needs, disabilities and mental health difficulties. They give consideration to and reflect on their views, difficulties, fears and aspirations. A member of staff described how the Woodlands Care Home DS0000055845.V268943.R01.S.doc Version 5.0 Page 16 team leaders and their teams had a key-worker approach to aspects of client care. Woodlands Care Home DS0000055845.V268943.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Residents, visitors and members of staff enjoy the use of very good premises. EVIDENCE: Each service user has a single bedroom with en-suite and shower. There is a bathroom on the ground floor. As well as soap dispensers and paper towels, alcohol-based gel dispensers are used throughout the premises. Good COSHH procedures and storage contributes to safety levels at the home. The home was clean, tidy and without odours. Bedroom accommodation is on the first floor with communal facilities on the ground floor. There are excellent communal facilities. Good car parking facilities are available. The premises are detached and have a garden at the rear. The conservatory is the designated smoking area. Bedrooms were decorated according to service user’s wishes and disposition (ie. most had many possessions and decorations: some had lesser levels of possessions displayed). Woodlands Care Home DS0000055845.V268943.R01.S.doc Version 5.0 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): 35 Service users care needs are met by members of staff who have received training to enable them to provide suitable support. This is particularly important because of the relatively high support needs of residents. EVIDENCE: The staffing rota indicated that there are generally 5 members of staff on duty during the day. Two members of staff (awake) are on duty at night. Appropriate records relating to members of staff are maintained (ie. Schedule 2: care home regulations). As referred to in Standard 23, care is taken to carry out all necessary recruitment checks to contribute to the protection of service users and their continuing wellbeing. The acting manager and members of staff outlined the range of training available to staff. This included encouragement/assistance given to complete NVQ Level 2/3 in Care, first aid (with many members of staff acquiring full first aid certificates), COSHH, food handling, moving of frail people, accredited medication training, and professional guidance on, for example, depression, challenging behaviours, person centred planning, epilepsy, aspects of learning disabilities and mental health difficulties. Woodlands Care Home DS0000055845.V268943.R01.S.doc Version 5.0 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 & 42. The home is well managed and safe procedures are followed. EVIDENCE: The manager (leaving this week on maternity leave) and the acting manager are completing the Registered Manager’s Award. Currently, the acting manager is completing the management element: the manager is completing the care element. The acting manager has NVQ Level 3 in Promoting Independence, the Certificate in Community Mental Health Care and the Team Leader’s Award. His full first aid certificate was not renewed at the end of its validity period (3 years). A full set of policy and procedure documents is available for care staff at the home. The documents required under the various care home regulation schedules were made available (ie. information relating to staff, information about residents, general records for care homes). Care plan records were up- Woodlands Care Home DS0000055845.V268943.R01.S.doc Version 5.0 Page 20 to-date and accurate in identifying care needs and monthly evaluations/reviews of care. Woodlands Care Home DS0000055845.V268943.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 LIFESTYLES Standard No Score 11 3 12 x 13 x 14 3 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Woodlands Care Home Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x x x x 3 x DS0000055845.V268943.R01.S.doc Version 5.0 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. Standard Regulation Requirement Timescale for action 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. 2 Refer to Standard YA1YA1 YA22YA22 Good Practice Recommendations It is acknowledged that a review of the service user’s guide is being carried so that services and facilities are described more accurately. It is acknowledged that a simplified complaints procedure will be displayed (in place of the existing one). 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