Inspection on 19/09/06 for Woodlands Cottage

This inspection was carried out on 19th September 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodlands Cottage 05/09/07

Woodlands Cottage 05/12/05

Woodlands Cottage 20/07/05

Woodlands Cottage 03/02/05

Woodlands Cottage 23/09/04

Woodlands Cottage 11/03/04

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 Cottage Fernlea Drive Choppington Northumberland NE62 5SR Lead Inspector Anne Brown Key Unannounced Inspection 19 and 20 September 2006 3.00 th th DS0000035040.V304903.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 DS0000035040.V304903.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. DS0000035040.V304903.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Cottage Address Fernlea Drive Choppington Northumberland NE62 5SR 01670 828487 01670 827525 communityhome@woodlandscottage.fsworld.co. uk Northumberland, Tyne & Wear NHS Trust 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) Mrs Julia Marley Care Home 4 Category(ies) of Learning disability (4) registration, with number of places DS0000035040.V304903.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th December 2005 Brief Description of the Service: Woodlands Cottage is a purpose built bungalow for four service users who have learning and physical disabilities. The home is situated in the community of Choppington and is close to local amenities. Service users are provided with single room accommodation and access to a range of aids and adaptations in line with their personal needs. Communal areas are provided as follows:- a kitchen, dining room and lounge; toilets and specialist bathrooms. The homes furnishings and fittings are of a high standard and the building is well maintained. Attractive garden areas are available. A small car park is provided to the front of the building. The home is not registered to provide nursing care. The fees are £857.00 per week. Inspection reports and information about the home are readily available. DS0000035040.V304903.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over five and a half hours. A tour of the premises was carried out and the care records were inspected along with the fire logbook, accident book, complaints records and minutes of meetings held in the home. Discussions were held with the manager and two members of staff. All the residents were present. Staff files were examined at the Trust’s headquarters. Questionnaires were sent to four relatives and two professionals who have contact with the home. No replies have been received. What the service does well: What has improved since the last inspection? Care plans have been updated and evaluated regularly. A new vehicle has been provided which is accessible to all the residents. DS0000035040.V304903.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. DS0000035040.V304903.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 DS0000035040.V304903.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 from evidence gathered both during and before the visit to this service. Service users have their individual needs assessed prior to admission. This ensures that the staff are aware of all their needs and are able to meet these. EVIDENCE: Assessments are carried out prior to moving into the home. These are completed by care managers and staff in the home. Service users are visited in their own home or hospital in order to ensure their needs can be met by the home. These are also discussed when the service user visits the home. No new admissions have taken place since December 2002. DS0000035040.V304903.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 and 10. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. There are care plans that contain guidelines for dealing with complex needs, which explain what staff need to do. Service users are encouraged to make decisions. Service users are encouraged to lead fulfilled lives and they are well supported by staff to take calculated risks. Confidentiality is respected in the home. EVIDENCE: Service users are well supported by staff and detailed care plans show the level of care and support the staff need to provide. Comprehensive guidelines, completed by relevant professionals, are in place to deal with the individual needs of the service users. DS0000035040.V304903.R01.S.doc Version 5.2 Page 10 Risk assessments are available on the case files. These assist the residents to lead fulfilling lives and they are well supported by staff to take calculated risks as necessary. A confidentiality policy is in place and is part of the staff induction-training programme. Each case file contains a statement to remind the staff that the information is confidential. All personal records are held in a secure location in the home. The staff have knowledge of equality and diversity issues and these are carefully considered when writing the care plans. DS0000035040.V304903.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, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The staff team assist and encourage service users to participate in appropriate activities. They also provide opportunities to link with the local community and participate in social and personal development activities. Service users are encouraged to keep in touch with family and friends. Service users’ rights are respected in all aspects of their lives. Meals are varied and healthy eating is encouraged. EVIDENCE: The staff team make every effort to ensure service users can participate in activities of their choice. The staff reported that on occasions, it has not been possible for service users to go out when staffing levels are low. This is due to the amount of staff supervision the service users require. DS0000035040.V304903.R01.S.doc Version 5.2 Page 12 Service users enjoy a variety of activities whenever possible. These include swimming, walking, visiting shopping centres, cinema, beauty sessions, music sessions and aromatherapy. Three service users have enjoyed a holiday this year and plans are being made to arrange a holiday for the other service user. The staff are also planning to take a service user to the Christmas Markets either in Germany or Belgium. The staff assist the service users to keep in touch with their friends and families. Visitors are welcome in the home at any time but are advised to telephone prior to their visit to ensure their relative is at home. Staff spoken to stated they receive training as part of their induction regarding basic care principles and that there is on going training for all staff regarding the rights of service users. The comprehensive policies and procedures manuals also provide information for staff about care of service users. Menus are varied and alternatives are always available. The staff were fully aware of the dietary needs of the service users and the assistance they required at mealtimes. DS0000035040.V304903.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 from evidence gathered both during and before the visit to this service. Service users are given the personal support they require and according to their preferences. Professional medical advice is sought, and reassessments are requested when necessary. An appropriate system is in place for dealing with medications, which protects the health of service users. EVIDENCE: The staff on duty were observed to be caring for the service users in such a way to promote and protect their privacy, dignity and independence. The staff team seek advice and support from relevant professionals to meet the health care needs of the service users. All appointments are recorded. Detailed care plans ensure that the staff are fully informed of the needs of the individual service users. A random sample of medication records and the system for storage and handling medications were looked at and found to be appropriate. DS0000035040.V304903.R01.S.doc Version 5.2 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 and 23. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home has a satisfactory complaints system and training in adult protection has been provided for the staff, which helps to protect the service users from abuse. EVIDENCE: A complaints procedure is in place and a complaints book is maintained. One complaint has been received since the last inspection. This has been investigated and was partially substantiated. A whistle blowing policy is in place and training in the protection of vulnerable adults is part of the staff induction programme. There are comprehensive policies and procedures in place to ensure service users are protected from abuse. One new staff member has been booked on a one-day training course for the protection of vulnerable adults. Existing staff members have attended this course. The home has demonstrated, in the past, their understanding of the protection of vulnerable adults procedure and their responsibilities to report concerns to Northumberland County Council and CSCI. Appropriate records, receipts and signatures are retained when dealing with money held on behalf of the service users. DS0000035040.V304903.R01.S.doc Version 5.2 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): 24 and 30. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The building is comfortable, pleasantly decorated and well maintained. There is a good standard of hygiene. EVIDENCE: A tour of the premises was carried out. All areas of the home were homely, comfortable and well furnished. Service users have their own bedrooms that are decorated and personalised according to the wishes and tastes of the individual. Bedrooms are equipped to ensure the comfort and safety of the individuals and specialist equipment is provided to promote independence. DS0000035040.V304903.R01.S.doc Version 5.2 Page 16 There is sufficient space for service users to enjoy internally and externally. Gardens are well maintained and provided with garden furniture. All areas of the home were clean, hygienic and free from offensive odours. Protective clothing is provided for the staff. There is no paper towel dispenser in the toilet located next to the dining room. DS0000035040.V304903.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, 33, 34, 35 and 36. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The staff team are well trained and competent to support the service users. Staffing levels are sometimes low which could place service users at risk. The recruitment policy and practice supports and protects the service users. The needs of the service users are met by appropriately trained staff. The staff team are well supported and supervised, so that they are able to do their job well. EVIDENCE: The majority of staff have achieved NVQ Level 2 or above. Mandatory health and safety training is updated on a regular basis. The staff confirmed that training is readily available to ensure they are competent to carry out their jobs. DS0000035040.V304903.R01.S.doc Version 5.2 Page 18 The staff files examined confirmed that Criminal Records Bureau checks had been carried out and two written references obtained. The files did not include photographs of the staff members. On the day of the inspection two members of care staff were on duty. The four service users were at home. The staff on duty stated there are normally three members of staff on duty during the day. However due to staff sickness and holidays this has not always been possible during the past few weeks. There is also a vacancy for a full-time home support worker. Staff confirmed that they are finding it difficult to cope at times due to the dependency levels of the service users. They were also concerned that sometimes service users are unable to access activities outside the home due to low staffing levels. A discussion was held with the manager during the second visit to the home and she confirmed the above information. She has reported this to her line manager who is due to meet with the care managers to discuss the situation. The manager stated that she is due to terminate her employed in the home at the end of the month. This will leave gaps in the duty rota. The locality manager confirmed that he is urgently seeking more staff to work in the home in order to meet staffing levels. He stated he would keep the Commission updated with this situation. The staff on duty were observed to be caring for the service users in a competent and sensitive manner. They were fully aware of the service users individual needs and preferences. The manager has produced a programme to ensure staff receive supervision on a regular basis. The staff on duty confirmed that they receive regular formal supervision sessions. DS0000035040.V304903.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, 40 and 42. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Staff ensure service users are at the heart of decision making in their own lives and involved in the running of the home. Records are up to date and well written. Systems and procedures are in place to ensure the well running of the home and to ensure the safety of residents and staff. EVIDENCE: The registered manager, Julia Marley has several years experience of working with people with learning disabilities. The staff team spend time with the residents and have developed ways to encourage them to communicate their wishes. DS0000035040.V304903.R01.S.doc Version 5.2 Page 20 The records that examined were well written and all entries were up to date. Staff are given training in moving and handling skills, fire safety, first aid and food hygiene. The fire logbook indicated that fire safety checks are carried out routinely. The key to open the side fire door is kept in the lock. If the key went missing, the staff members would not be able to open the door in an emergency. Staff meetings take place regularly and the minutes were available for inspection. DS0000035040.V304903.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 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 3 X 2 X DS0000035040.V304903.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. 2. 3. 4. Standard YA12 YA30 YA33 YA42 Regulation 16(2)(m) 13(3) 18(1)(a) 23(4)(b) Requirement Timescale for action 31/10/06 Service users must be supported to access activities of their choice. Paper towels must be provided in 31/10/06 the toilet next to the dining room to control the spread of infection. Staffing levels must be reviewed 31/10/06 in accordance with the needs of the service users. All staff members must be 09/10/06 provided with a key to the fire escape door. 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 DS0000035040.V304903.R01.S.doc Version 5.2 Page 23 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 DS0000035040.V304903.R01.S.doc Version 5.2 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. 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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