Inspection on 14/11/05 for Woodlands Close, 1

This inspection was carried out on 14th November 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 found no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodlands Close, 1 16/08/07

Woodlands Close, 1 05/09/06

Woodlands Close, 1 21/06/05

Woodlands Close, 1 30/11/04

Woodlands Close, 1 23/06/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Woodlands Close, 1 1 Woodlands Close Preston Village North Shields Tyne And Wear NE29 9JS Lead Inspector Deborah Haugh Announced Inspection 14th November 2005 11:00 Woodlands Close, 1 DS0000000359.V252404.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 Close, 1 DS0000000359.V252404.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 Close, 1 DS0000000359.V252404.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Woodlands Close, 1 Address 1 Woodlands Close Preston Village North Shields Tyne And Wear NE29 9JS 0191 2966953 0191 2966953 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) Northern Life Care Limited T/A U.B.U. Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Woodlands Close, 1 DS0000000359.V252404.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st June 2005 Brief Description of the Service: 1 Woodlands Close is a large bungalow which has been adapted to provide residential care for three male service users with profound learning and physical disabilities. The home is in keeping with the local community and is in close proximity to local amenities. A mini bus is providing for transporting the service users to venues of their choice. The premises are spacious and the three service users have their own bedroom. One room is provided with en suite facilities. There is ample car parking and a small garden and patio is available at the rear of the premises. Woodlands Close, 1 DS0000000359.V252404.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection took place on 14/11/05 from 11.00 until 4pm. There is no Registered Manager at this time. The proposed manager Jayne Bowmer and the relief manager Melanie Cruddis were on duty during the visit. Time was spent looking at medication, recruitment, finances, care planning arrangements and nutrition. Time was also spent observing the contact between the service users and staff. The 3 service users who live at No 1 Woodlands Close were at home. The service users are unable to express their views about their home. Staff described their approaches to caring for the service users. What the service does well: What has improved since the last inspection? The requirements made at the last inspection have been addressed in relation to health and safety, medication and quality assurance. Woodlands Close, 1 DS0000000359.V252404.R01.S.doc Version 5.0 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 Close, 1 DS0000000359.V252404.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 Close, 1 DS0000000359.V252404.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): 2 The needs of service users have been assessed before they were admitted. EVIDENCE: No one has been admitted in the home since 1999. Assessments were completed at the time, which looked at the needs and wishes of the service users. Woodlands Close, 1 DS0000000359.V252404.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 Service users have care plans, which have their needs met but do not always enable them to fulfil their potential. EVIDENCE: One care plan was examined, staff discussed their approaches to caring for the service users and interactions between service users and staff were observed. Care plans have been updated to reflect changes to practice. Service users personal needs are comprehensive and they include information on the support package from the organisation and other agencies. Communication with the service users is complex and the various methods developed by the staff are clearly identified. Staff demonstrated that they appear to know the service users well. Personal Plans and Ambitions are identified each year but 2005/6 have not been completed due to changes in the management of the home. Service users activities and potential for new experiences are not being identified or at times provided. Woodlands Close, 1 DS0000000359.V252404.R01.S.doc Version 5.0 Page 10 Woodlands Close, 1 DS0000000359.V252404.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 & 17 Service users are not fulfilling their personal goals and ambitions. Service users are not always engaging in activities they want to do. Service users receive wholesome nutritious food so their dietary needs are being met. EVIDENCE: As mentioned NMS 6 targeted ambitions have not been completed for 2005/6. Service users activities and potential for new experiences are not being identified or at times provided. At times activities are not occurring due to staffing and having a driver on duty. Staffing levels must meet the needs of service users. (NMS 33) It is recorded that a service user does not appear to enjoy two of the activities provided. During the inspection two service users went out to the local shops. Later on two people enjoyed a foot spa and massage. Another service user went out with his parents. Woodlands Close, 1 DS0000000359.V252404.R01.S.doc Version 5.0 Page 12 A 4-week menu was audited and service users receive a balanced, varied and nutritious diet. Woodlands Close, 1 DS0000000359.V252404.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): 19 & 20 The health needs of residents are being met. The medication arrangements must improve so that service users are protected. EVIDENCE: The staff monitor service users health needs, which is recorded in the care plans. Routine health checks are carried out and service users attend appointments with relevant health care professionals with staff. Medication arrangements were audited and concerns were raised. The homes supplying pharmacist should be asked to complete a full audit. Woodlands Close, 1 DS0000000359.V252404.R01.S.doc Version 5.0 Page 14 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 Service users or their advocates are supported to make complaints. Service users are protected from potential abuse, neglect and harm but financial records must improve. EVIDENCE: New care plans by the relief manager have provided guidance on ensuring that service users are supported to sharing concerns and complaints. Staff have received training in the Protection of Vulnerable Adults and have demonstrated their knowledge of Whistle Blowing where they would report poor practice or concerns. Service users personal finances that are looked after by the home were checked. Amounts were correct and there are external and internal audits in place. However two signatures must be recorded at each transaction. A service user has been charged for a replacement inner tube for his wheelchair. Servicing and maintenance arrangements are normally in place to repair faults such as this. The payment must be investigated and CSCI informed. Woodlands Close, 1 DS0000000359.V252404.R01.S.doc Version 5.0 Page 15 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): 26 Service users are unable to secure their personal belongings in their bedrooms. EVIDENCE: Service users do not have a lockable storage facility to secure their personal belongings. Woodlands Close, 1 DS0000000359.V252404.R01.S.doc Version 5.0 Page 16 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, 33, 34 & 35 Staffing numbers have not always been appropriate to the assessed needs of the service users, size and layout and purpose of the home. People who have been vetted care for service users but records must be available in the home. Service users are cared for by staff who are trained to NVQ Level 2 and who have completed other appropriate training. EVIDENCE: The home has not always maintained the level of staffing in accordance with previous agreements with the local authority and this should reflect the size and layout of the building and the needs of the service users currently living in the home. The current levels of staffing are a minimum of 3 care staff on duty during the day and 1 waking night staff with 1 person sleeping in. At times there have not been 3 staff on duty during the day. 56 of staff are qualified to NVQ Level 2 via the Learning Disability Award Framework (LDAF). Woodlands Close, 1 DS0000000359.V252404.R01.S.doc Version 5.0 Page 17 Staff receive training in Protection of Vulnerable Adults, Pressure Care, Fire Instruction, Personal Futures Planning, Culture Day and mandatory training. Staff recruitment records were examined. Adequate measures are in place when recruiting staff. Checks are made including the Criminal Records Bureau. However a newly recruited member of staff’s records were not available in the home. Records were faxed from the organisations Headquarters in Harrogate. A photograph was not available. Woodlands Close, 1 DS0000000359.V252404.R01.S.doc Version 5.0 Page 18 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): 39 & 42 Quality Assurance systems are in place so the service is formally audited externally. Systems are in place to protect service users from health and safety hazards. EVIDENCE: Monthly visits and reports on the conduct of the home are now completed provided to CSCI. Staff now receive fire instruction at 3 monthly intervals and the electric wiring certificate has been renewed. Overall the home is maintained safely and hazards are identified and reduced. However the lighting in the office is quite poor. Staff are expected to use a Visual Display Unit and maintain records. Woodlands Close, 1 DS0000000359.V252404.R01.S.doc Version 5.0 Page 19 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 X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X 2 X X X X LIFESTYLES Standard No Score 11 2 12 X 13 X 14 2 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 4 2 2 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Woodlands Close, 1 Score X 3 1 X Standard No 37 38 39 40 41 42 43 Score X X 3 X X 2 X DS0000000359.V252404.R01.S.doc Version 5.0 Page 20 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 Care plans must identify the activities and personal development goals of service users. Service users must have a lockable storage facility The Registered person shall ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health ands welfare of service users. Medication issues must be addressed; 1. Prescribed medication must be entered on Medication Administration Records (MAR). 2.PRN ‘when required medication’ must have an agreed care plan explaining its use. 3. Handwritten records must be signed by 2 staff. 4.Date creams when opened and use one at a time.5. Agency staff must sign MAR as a witness instead of an asterisk. 6. A controlled drugs register must be obtained. 7. A pharmacist DS0000000359.V252404.R01.S.doc YA14YA6YA11 15 Timescale for action 31/12/05 2. 3. YA26 YA33 23 18 30/11/05 14/11/05 4. YA20 13 31/12/05 Woodlands Close, 1 Version 5.0 Page 21 5 YA23 Schedule 4 6 7 YA42 YA34 23 Schedule 2 audit must occur due to concerns raised at this inspection. Two signatures must be 30/11/05 obtained for records in relation to service users finances. The transaction regarding the wheelchair inner tube must be investigated and CSCI informed. Review the lighting in the office 31/12/05 Records in relation to recruitment must be available in the home and a photograph of staff provided. 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Woodlands Close, 1 DS0000000359.V252404.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Close, 1 DS0000000359.V252404.R01.S.doc Version 5.0 Page 23 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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