Inspection on 14/12/06 for Woodlands Lodge And Cottage

This inspection was carried out on 14th December 2006.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodlands Lodge And Cottage 17/09/09

Woodlands Lodge And Cottage 22/05/08

Woodlands Lodge And Cottage 24/05/07

Woodlands Lodge And Cottage 11/07/06

Woodlands Lodge And Cottage 07/12/05

Woodlands Lodge And Cottage 10/06/05

Woodlands Lodge And Cottage 08/03/05

Woodlands Lodge And Cottage 29/09/04

Similar services:

Ruskin Lodge

Clover House

Dystlegh Grange

The Good Companions

Cuerden Grange Rest Home

Springfield Cottage

Parkside

Park Lodge

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

CARE HOME ADULTS 18-65 Woodlands Lodge And Cottage 95b Byrons Lane Macclesfield Cheshire SK11 7JS Lead Inspector Ms Julie Porter Unannounced Inspection 14th December 2006 11:00 Woodlands Lodge And Cottage DS0000006618.V316008.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodlands Lodge And Cottage DS0000006618.V316008.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Woodlands Lodge And Cottage DS0000006618.V316008.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Lodge And Cottage Address 95b Byrons Lane Macclesfield Cheshire SK11 7JS 01625 610049 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) Rossendale Trust Rachel Windelinckx Care Home 16 Category(ies) of Learning disability (16), Learning disability over registration, with number 65 years of age (1), Physical disability (4), of places Physical disability over 65 years of age (4) Woodlands Lodge And Cottage DS0000006618.V316008.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide care for up to 16 people including: * Up to 16 people in the category of LD (learning disabilities) * 1 named person in the category of LD(E) (learning disabilities over the age of 65) * Up to 4 people in the category of PD (physical disability) * Up to 4 people in the category of PD(E) (physical disability over the age of 65) The registered provider must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection The registered provider must provide staff to meet the dependency needs of service users at all times and shall comply with any guidelines, which may be issued through the Commission for Social Care Inspection The matters detailed in the attached schedule of requirements must be completed within the stated timescales 11th July 2006 2. 3. 4. Date of last inspection Brief Description of the Service: Woodlands Lodge and Cottage is registered with the CSCI to provide care for 16 service users within the category of learning disability, 15 of whom must be under the age of 65 and one over the age of 65 years of age. The home is a detached house on the outskirts of Macclesfield town centre. The house is in pleasant surroundings in a quiet residential cul de sac off the main road. The home is part of the service provided by the Rossendale Trust, a charitable organisation. The Rossendale Trust was established in 1973 and provides both residential and day care for adults with learning disabilities. On the day of this site visit there were 15 service users living at Woodlands Cottage and Lodge. Accommodation is in single and shared bedrooms on the ground and first floors. A number of these bedrooms are smaller than the sizes identified in the National Minimum Standards (Standard 25 of the National Minimum Standards for Care Homes for Younger Adults). However, as the home was registered and in use before 31 March 2002, the home does not have to meet this standard. Local amenities, in the village of Sutton and at other Rossendale Trust services, are a short drive away. Woodlands Lodge And Cottage DS0000006618.V316008.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit took place on the 14 December 2006 and lasted 4 hours. The visit was carried out by one inspector. This visit was just one part of the inspection. Before the visit the home owner/manager was asked to complete a questionnaire to provide up to date information about services in the home. Questionnaires were also made available for residents, families, and health and social care professionals to find out their views. Other information received by CSCI since the last key inspection was also reviewed. During the visit various records and the premises were looked at. A number of residents and relatives were also spoken with and they gave their views about the service. What the service does well: What has improved since the last inspection? What they could do better: Woodlands Lodge And Cottage DS0000006618.V316008.R01.S.doc Version 5.2 Page 6 Contracts showing the terms and conditions of residence must be available so that residents and relatives know their rights. Work needs to be completed in relation to assessing risks for both the environment and in respect of activities for residents. Prompt action must be taken when risks are identified so that the risk to residents is minimised and they are kept as safe as possible. Staff must receive mandatory training, specialist training and medicines administration training to ensure that they have the skills necessary to provide care for the residents safely. References and CRB checks need to be obtained for all staff before they start working in the home so that residents’ welfare is safeguarded. 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. The summary of this inspection report can be made available in other formats on request. Woodlands Lodge And Cottage DS0000006618.V316008.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodlands Lodge And Cottage DS0000006618.V316008.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2&5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a procedure for new residents moving into the home although it has not been used for some years. Copies of contracts showing terms and conditions of living at the home must be available to residents and their families to ensure that they know what they can expect from the home. EVIDENCE: Processes are in place to assess prospective new service users before they are admitted to the home, although there have been no new admissions for a number of years. Two resident’s files were checked and neither contained contracts or statements of the terms and conditions for living in the home. Woodlands Lodge And Cottage DS0000006618.V316008.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6&9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Accurate up-to-date information must be recorded in residents’ plans to ensure they receive the care they need. EVIDENCE: At the last key inspection, there was ample evidence to show that residents are enabled to make decisions about their lives, with necessary support so this was not checked again during this visit. Three residents’ care plans were inspected and included timetables and information about the residents’ activities. One plan identified that the resident had had a skin complaint since April 05. After various courses of treatment, the resident saw a consultant on 8 December 2005. The consultant prescribed medication for a two-week period; the records made about the resident on 12 January 2006 state ‘no change’. No further information was available to identify any further action being taken. The manager said that the Woodlands Lodge And Cottage DS0000006618.V316008.R01.S.doc Version 5.2 Page 10 condition had cleared up. When asked how she was certain of this she said that the resident’s family would have informed her if it had not. Documentation is now available for staff to use in assessing risks for residents relating to: medication, physical disability, moving and handling, eyesight, speech and hearing and eating. Work had not yet started on one of the resident’s care plans inspected. Some evidence was seen that risks associated with one resident’s activities of walking around the property until late into the evening had been assessed. Although the risk assessment identifies that work on resurfacing the area around the home needs to be done, the funds are not yet available. See also standard 24. Woodlands Lodge And Cottage DS0000006618.V316008.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 12,13,15,16, and 17 were met at the last key inspection so were not looked at again during this visit. Woodlands Lodge And Cottage DS0000006618.V316008.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff must receive training relating to medicine administration so that residents’ welfare is safeguarded. EVIDENCE: At the last key inspection of this home, there was evidence to show that residents were given the support they needed to meet their identified needs so this was not looked at again during this visit. Medication for the home is provided by the pharmacy in a monitored dosage system. Fifteen of the home’s twenty-two staff give out medicines to residents when they are on duty. None of these staff have attended recent medication administration training. The manager said she had asked the training officer to provide medication training but this has not been made available. Woodlands Lodge And Cottage DS0000006618.V316008.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The majority of staff have received adult protection training so that staff are aware of their responsibility in protecting residents from harm. EVIDENCE: Although the manager did not provide the requested information about complaints in the questionnaire she completed, the complaints log that has been developed since the last visit to the home showed that two complaints had been received, one on 17 July and one on 15 October 2006. The record showed what the complaints were, how they had been dealt with, and the outcome. Two completed questionnaires had been returned to CSCI from residents who had both commented that they knew who to speak with if they were unhappy with any aspect of the service. Information provided by the manager of the home identified that nineteen staff have received training relating to adult protection since the last inspection. Woodlands Lodge And Cottage DS0000006618.V316008.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although some improvements have been made to the fabric of the building, some problems have not been resolved, leaving residents and staff exposed to unnecessary risk. EVIDENCE: A guided tour of the home was done with the manager. It included all communal areas and residents’ bedrooms. All areas of the home were clean and fresh. The Environmental Health Officer visited the home on the 21 June 2006 and inspected the kitchen in Woodlands Lodge. The report states that the home should “progressively renew the worn kitchen units.” The manager said that work to replace/repair the kitchen units had been agreed; this should start in January 2007 and the kitchen would be painted some time after that. Woodlands Lodge And Cottage DS0000006618.V316008.R01.S.doc Version 5.2 Page 15 Following the last inspection repairs have been made to broken glass in the lounge and bedroom windows. Two residents’ bedrooms have been painted and decoration of the hall, stairs and landing is planned for January. A portable ramp has been provided to give easy access to the bedroom of a resident who uses a wheelchair. Access to the rear of the property from the cottage is down an unsteady paving slab. At the rear of the home the ground remains uneven and poses a risk to residents with mobility difficulties as identified on one resident’s care plan. This was discussed with the manager who said that Rossendale Trust had applied for a grant to level the pathways but she was unsure of its progress. The gate at the rear of the property that gives direct access via a steep embankment to the railway line has now been secured. Woodlands Lodge And Cottage DS0000006618.V316008.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Poor recruitment processes and staff training not being available could lead to residents being at risk of harm or poor practice. EVIDENCE: Job descriptions are available for all staff in the home. Information provided by the manager on 10 November 2006 identifies that 20 of staff have achieved a National Vocational Qualification (NVQ) level 2 or above. One staff member has enrolled this year for NVQ 2. Some improvement has been made since the last visit as four staff have completed training in moving and handling, three have completed 1st Aid and nineteen have done adult protection training. Training is not yet in place to ensure all staff achieve other minimum mandatory training in relation to health and safety, moving and handling, emergency aid, food hygiene and fire safety. Woodlands Lodge And Cottage DS0000006618.V316008.R01.S.doc Version 5.2 Page 17 There was no evidence available to suggest that staff are offered training relating to the specific needs of the residents in the home, for example autism awareness and cerebral palsy. The majority of staff have worked in the home for a number of years and have got to know the residents well. Two staff files were inspected. One staff member’s file contained a completed application form, a set of interview questions, one personal reference and also identified that she had started work in the home before a Criminal Record Bureau clearance was applied for or obtained. After a discussion with the manager it was agreed that the staff member would not work in the home until such a time that full satisfactory information in accordance with Schedule 2 of the Care Homes Regulations was obtained. CSCI sent a warning letter to the home regarding this matter on 15 December 2006 to ensure that the managers and trustees of the organisation were aware of this situation and seeking their urgent action to rectify it. Woodlands Lodge And Cottage DS0000006618.V316008.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Health and safety training for staff has not been updated and internal monitoring processes are not in place to ensure continuing development of the service in the best interests of the service users. EVIDENCE: The manager is registered with the Commission for Social care inspection and said that she is due to complete her registered managers award by September 2007. East Cheshire Advocacy service has been involved with the home since the last inspection with an aim to establish the views of the residents regarding the quality of life in the home. A report of their findings is available in the home. The manager confirmed that visits by a nominated person in accordance with Regulation 26 of the Care Homes Regulations have not taken place. A visit Woodlands Lodge And Cottage DS0000006618.V316008.R01.S.doc Version 5.2 Page 19 had been arranged with the manager for the week following this site visit; however these visits must be unannounced. There was nothing to show that the home has a training programme to ensure that all the mandatory training in relation to aspects of health and safety takes place. While service contracts are in place for gas and electrical equipment, prompt action has not taken to ensure a safe environment for residents and staff in relation to the outdoor steps and pathways. Woodlands Lodge And Cottage DS0000006618.V316008.R01.S.doc Version 5.2 Page 20 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 2 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X 3 X 2 X X 2 X Woodlands Lodge And Cottage DS0000006618.V316008.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? YES 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 YA5 Regulation 5 Timescale for action Residents must be given a 15/02/07 written contract or statement of the terms and conditions of residence at the home. These should include information about the accommodation provided and the method of payment of their fees. Previous timescale of 16/03/06 and 31/08/06 not met The manager must ensure that 15/02/07 residents’ care plans contain accurate up to date information Risk assessments should be in 28/02/07 place to identify what steps should be taken to minimise risk for activities that the residents are involved in. Previous timescale of 31/05/06 and 31/08/06 not met. Staff must receive training in 28/02/07 relation to medication administration. Previous timescale of 30/09/06 not met. The home must be kept in a 31/01/07 good state of repair, in relation to the kitchen. Previous timescale of 30/10/06 not met. DS0000006618.V316008.R01.S.doc Version 5.2 Page 22 Requirement 2. 3. YA6 YA9 15(2)(b) 13(4) 4. YA20 18(1)(c) 5. YA24 23 Woodlands Lodge And Cottage 6. YA24 23 7. YA24 23 8. YA32 18 9. YA34 19 10. YA39 26 The home must be kept reasonably decorated. Previous timescale of 30/10/06 not met. The grounds of the home must be suitable for, and safe for the residents and staff in the home Previous timescale of 30/10/06 not met. A training plan must be developed to ensure that staff receive training appropriate to the work they perform including mandatory training Previous timescale of 30/09/06 not met. Criminal Records Bureau disclosures must be obtained for all new staff working in the home before they start work. The registered person must ensure that full information regarding staff (as set out in Schedule 2 of the Care Home Regulation 2000) is available before they commence employment. Previous timescale of 30/05/06 and 30/09/06 not met. Visits to the home must be undertaken by a nominated person for the trustees at least once a month and must be unannounced and a report produced and supplied to the Commission for Social care Inspection. Previous timescale of 16/03/06 and 30/09/06 not met. 31/01/07 15/03/07 28/02/07 14/12/06 31/01/07 Woodlands Lodge And Cottage DS0000006618.V316008.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations Details about the services the home can offer, i.e. service user guide and statement of purpose should be produced in a format suitable for people with learning disabilities. (Recommendation made at previous inspection) Care plans should be produced in a format the residents can understand. (Recommendation made at previous inspection) 2. YA6 Woodlands Lodge And Cottage DS0000006618.V316008.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Lodge And Cottage DS0000006618.V316008.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!