Inspection on 18/07/05 for Woodlands Care Home

This inspection was carried out on 18th July 2005.

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 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 01/12/05

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 Lead Inspector Martin Bayne Unannounced 18/7/05 10:00am 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 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 Stationary 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 H54 S55845 Woodlands V234860 180705.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Woodlands Care Home Address 375 Woodlands Road, Netley Marsh, Totton, Hampshire, SO40 7GB Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 02380 871704 Truecare Group Limited Miss Danniella Kirsty Andre CRH 6 Category(ies) of LD- Learning Disability: 6 registration, with number MD- Mental Disorder: 6 of places Woodlands Care Home H54 S55845 Woodlands V234860 180705.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1- Service users may only be admitted in the MD category if they also have a learning disability. 2- Service users may only be accomodated between 18 and 64 years of age. Date of last inspection 9/2/05 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 of the service users are female. The home is located in the village of Netley Marsh, close to the local shops and pub. The home itself is a large detached property with bedrooms on the first floor and communal areas on the ground floor. All of the bedrooms are for single occupancy and have ensuite shower and bathroom facilities. Service users share a large lounge/dining area with adjoining conservatory, leading to a large enclosed garden. The home has a large kitchen and separate laundry room. Woodlands Care Home H54 S55845 Woodlands V234860 180705.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector was introduced to the residents, one of whom gave a tour of the building. The assessment and procedures for admitting new people to the home, together with relevant paperwork were discussed and found to ensure that the home can meet the needs of those people who are admitted. Service users medical and social needs were met through comprehensive care planning. The service users said that the food at the home was of a good standard and that they could have what they liked to eat. The recruitment records for two staff were viewed and these were found to contain all the paperwork required. There were no requirements made at the inspection, however four recommendations were made and are detailed within the report. What the service does well: What has improved since the last inspection? Since the last inspection the home has devised better recording in instances where restrictions have been made to personal freedoms of service users, linked to the care planning process. Woodlands Care Home H54 S55845 Woodlands V234860 180705.doc Version 1.30 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 Care Home H54 S55845 Woodlands V234860 180705.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Woodlands Care Home H54 S55845 Woodlands V234860 180705.doc Version 1.30 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 standard(s) 2 & 5 Service users needs are assessed and they are fully informed before they have to make a choice to move to the home. EVIDENCE: Since the last inspection there have been no new service users admitted to the home. In the event of a vacancy, a senior manager from the organization will assess the person’s needs to see whether one of the homes within the organization would be able to meet their needs. If deemed appropriate the referral would be passed to the manager of Woodlands who would then visit the person and assess whether their needs could be met at the home. Visits are then arranged with that person to see whether they choose to move to the home. Throughout the inspection two service users records were used to track required paperwork. It was found that in both instances copies of the initial assessments were on file together with the care management assessment. Within both personal files was a copy of the terms and conditions of residence that had been signed by the service user. The manager said that each person is also given a copy of the home’ Service User Guide. Woodlands Care Home H54 S55845 Woodlands V234860 180705.doc Version 1.30 Page 9 Woodlands Care Home H54 S55845 Woodlands V234860 180705.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 & 9 Service users needs are met through thorough and detailed care plans. Staff and residents would be better protected through more detailed recording where restraint has been used. EVIDENCE: The home was found to have detailed and comprehensive care plans that have been developed through the assessment process. The plans were also up to date and had been reviewed. The care plans also reflected the needs discussed with the individuals concerned. It was reported that service users are involved in drawing up the care plans and their reviews. At the last inspection a requirement was made that where any restrictions on personal freedoms were made, this should be reflected in the care plans. Since the last inspection the home has added another sheet to the care plans recording the instances and reasons for any restrictions on freedoms. On occasions the staff at the home have to use restraint. The care plans record the triggers that can lead to challenging behaviour, signs that a service user is becoming angry or distressed and techniques that that can diffuse situations. All the staff have been trained in managing challenging behaviour. Woodlands Care Home H54 S55845 Woodlands V234860 180705.doc Version 1.30 Page 11 Any instance of restraint is recorded and reported to CSCI through Regulation 37 notices. An instance where restraint had had to be used was discussed and it was recommended that more detail be recorded as to why restraint had had to be used. Risk assessment is incorporated into the care planning system and individual risk assessments were recorded and reviewed where needed. Woodlands Care Home H54 S55845 Woodlands V234860 180705.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 & 17 Service users benefit from a full programme of activities, tailored to their individual needs. EVIDENCE: Each service user has a care plan relating to community access. They are also encouraged to take part in the domestic running of the home to develop their independent living skills. One of the service users told the inspector that they were waiting for a place in a flat as they had learnt to live more independently. The two service users tracked through the inspection were found to have full programme of activities meeting leisure and personal development needs. Between the two were the following activities; life skills, horse riding, visits to the gym, line dancing, community access, social group, drama and sailing. The home has the use of two house cars for getting service users to and from activities. Woodlands Care Home H54 S55845 Woodlands V234860 180705.doc Version 1.30 Page 13 All of the residents have contact with their families and are supported to maintain these relationships. There was evidence on one of the care plans of a service user being supported with a personal relationship. Three of the residents spoken with said that the food was of a good standard and that they were able to choose what they liked to eat. The home uses a seasonal menu and when this changes residents select their three favourite dishes and these are incorporated into the menu. One service user takes a turn each week to assist the staff with the main shopping outing. The manger reported that there was a sufficient food budget that she has responsibility for. The home caters to the diabetic needs of two of the service users. Three of the service users have had dietician input. Woodlands Care Home H54 S55845 Woodlands V234860 180705.doc Version 1.30 Page 14 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 standard(s) 19 & 20 Service users’ health needs are met through referrals to appropriate professionals. EVIDENCE: The care plans revealed that the home meets the medical needs of service users. One of service users is subjected to a CPA and the roles of all professionals involved in this person’s care were recorded. The staff are working with a psychologist assisting one resident who presents with challenging behaviour. Other residents have ongoing assistance from a psychiatrist. All of the residents are registered with a local GP and are supported to attend appointments. Other health needs, such as dentistry, chiropody and eye care are attended to. The medication procedures were discussed and followed through. All of the staff who administer medication have been trained. Residents are assessed as to whether they can administer their own medication through a risk assessment process. One of the service users tracked through the inspection has assistance from the staff to manager their medication. The home has a metal medication cabinet that is kept locked with the senior member of staff Woodlands Care Home H54 S55845 Woodlands V234860 180705.doc Version 1.30 Page 15 on duty holding the key. The cabinet was seen and medications that had been dispensed by the pharmacist into a unit dosage system were stored correctly. The medication administration records for all of the service users were seen and correctly recorded with no gaps within the records. The staff who administer insulin to one service user have received training from the district nurse to be competent to undertake this procedure. The procedure for the administration of PRN medication is that authorization must be granted from a manager within the organization. Woodlands Care Home H54 S55845 Woodlands V234860 180705.doc Version 1.30 Page 16 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 standard(s) 22 & 23 Service user finances would be better protected through the use of a second safe with a recorded handover of monies each shift change. EVIDENCE: The complaints procedure is displayed in the hallway and gives the address and telephone number of CSCI. A pictorial version is contained within the Service User Guide and each service user is given a copy of this document when they move into the home. Since the last inspection there have been two complaints made to the manager one from a relative that was resolved and one from a neighbour that is ongoing. The home has a complaints log where complaints are recorded. Since the last inspection there has been one adult protection conference in respect of the theft of a sum of a service user’s money. The conference recommended purchasing a second safe, into which the manager can decant smaller sums of money for the staff and service user to have access. The organization has granted authorization for the second safe but it has yet to be purchased. It is recommended that this put in place together with a recorded auditing of monies handed over each shift to the person responsible for the keys. All of the staff have received training in adult protection and the home has copies of all the relevant policies and procedures. Woodlands Care Home H54 S55845 Woodlands V234860 180705.doc Version 1.30 Page 17 Woodlands Care Home H54 S55845 Woodlands V234860 180705.doc Version 1.30 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 & 25 Residents benefit from a spacious and comfortable environment. EVIDENCE: The home is spacious and set in its own large enclosed garden. Residents have their own bedrooms that have ensuite WC and shower facility. The home also has a large bathroom on the ground floor should service users wish to take a bath. The home has a large communal lounge/dining area that leads into the conservatory, the designated smoking area. The bedrooms have locks so that service users can lock their rooms. On the day of the visit the home was clean and in reasonable decorative order throughout. During the inspection one of the residents showed their room to the inspector and it was evident that service users can bring their own possessions to personalize their rooms. Their bedroom also contained all of the required furniture as detailed within the standards. Woodlands Care Home H54 S55845 Woodlands V234860 180705.doc Version 1.30 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 & 26 Appropriate recruitment procedures and ongoing training both protect and benefit service users. EVIDENCE: The manager informed that there were generally five members of staff on duty during the daytimes. The recruitment records for two staff were seen. These contained a copy of their completed application form that contains a copy of a rehabilitation of offender’s declaration, two references, a CRB check and a photograph. It is recommended that the application form be amended so as to obtain a reference from the applicant’s last place of work involving vulnerable adults. These records detailed training undertaken by the staff, which was appropriate to the service. Training included; NVQ level 2, induction, basic food hygiene, fire safety training, breakaway, first aid, autism and managing violence and aggression. Woodlands Care Home H54 S55845 Woodlands V234860 180705.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 The home would benefit from an increase in hours that the manager devotes to management responsibilities. EVIDENCE: The manager reported that she has sixteen hours dedicated to management functions and the rest of the time she works as part of the rota. It is recommended that due to increased management responsibility with devolved budgets, health and safety and additional staff recruitment responsibility, the management hours be increased to at least thirty hours per week. Woodlands Care Home H54 S55845 Woodlands V234860 180705.doc Version 1.30 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 x 3 x x 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 x x x x Standard No 11 12 13 14 15 16 17 x 3 3 3 3 x 3 Standard No 31 32 33 34 35 36 Score x x 3 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Woodlands Care Home Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 x x x x x x H54 S55845 Woodlands V234860 180705.doc Version 1.30 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 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. 3. Refer to Standard 7 23 34 Good Practice Recommendations It is recommended that more detail is recorded in cases of restraint as to why restraint was necessary. It is recommended that a second safe be purchased and money is recorded as part of shift handover procedure. It is recommended that the staff application form be amended to request a reference from the applicants last empolyment of not less than three months that involved working with children or vulnerable adults. It is recommended that the hours the registered manager is supernumerary to the rota be increased. 4. 37 Woodlands Care Home H54 S55845 Woodlands V234860 180705.doc Version 1.30 Page 23 Commission for Social Care Inspection 4th Floor- Overline House Blechynden Terrace Southampton Hampshire 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 Care Home H54 S55845 Woodlands V234860 180705.doc Version 1.30 Page 24 - 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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