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Inspection on 07/12/05 for Woodlands Lodge And Cottage

Also see our care home review for Woodlands Lodge And Cottage for more information

This inspection was carried out on 7th December 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 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Staff have worked in the home for a number of years and know the residents well. Residents have lived in the home for a number of years and regard it as home.

What has improved since the last inspection?

Some improvements have been made to the recording on care plans. Window restrictors have been fitted to minimise the risk of falls. The new laundry is now fully operational and ramped access to the property is available.

CARE HOME ADULTS 18-65 Woodlands Lodge And Cottage 95b Byrons Lane Macclesfield Cheshire SK11 7JS Lead Inspector Ms Julie Porter Unannounced Inspection 7 December 2005 &16 March 2006 10:00 Woodlands Lodge And Cottage DS0000006618.V260678.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 Lodge And Cottage DS0000006618.V260678.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 Lodge And Cottage DS0000006618.V260678.R01.S.doc Version 5.0 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.V260678.R01.S.doc Version 5.0 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 10th June 2005 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 service is provided within a detached property located on the outskirts of Macclesfield town centre. The service is set within pleasant surroundings in a quiet residential cul de sac off the main road. The premises are part of the service provided by the Rossendale Trust, a charitable body.The Rossendale Trust was established in 1973 and provides both residential and day care for adults with learning disabilities.On the day of the inspection there were 15 service users living at Woodlands cottage and lodge. Accommodation is in single and shared bedrooms situated 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.V260678.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An initial visit was made to the home on 07 December 2005 and included a meeting with the Trustees of the service at the Rossendale Hall site. The inspection was concluded on 16 March and involved a review of the personnel records. The manager of the home completed the pre-inspection questionnaire and information from that is included in this report. The inspection also included a tour of the premises, meeting with residents and staff. What the service does well: What has improved since the last inspection? What they could do better: Contract and terms and conditions of living in the home must be provided to ensure residents and families know their rights. Care plans must be reviewed regularly to ensure residents receive the care they need, any risks associated with activities or daily living must be assessed to ensure they stay as safe as possible. Staff must receive training appropriate to the work they perform, including a rolling program of mandatory training. Robust recruitment processes must be adopted to protect residents. Visits to the home must be undertaken by a nominated person (Regulation 26 visits) and a report produced and forwarded to the Commission for Social Care Inspection. Woodlands Lodge And Cottage DS0000006618.V260678.R01.S.doc Version 5.0 Page 6 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 Lodge And Cottage DS0000006618.V260678.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 Lodge And Cottage DS0000006618.V260678.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): 5 In the absence of contract and terms and conditions of living in the home, residents and families are not provided with full information regarding the service. EVIDENCE: Contracts between the home and the service user, detailing the terms and conditions of living in the home and what is included and what is not, was not available. A requirement was made at the last inspection regarding contracts and this remains outstanding. See requirement 1 Woodlands Lodge And Cottage DS0000006618.V260678.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&9 Staff working in the home know the residents well, but in the absence of up to date accurate information the residents may not get the care they need. EVIDENCE: Two residents files were reviewed as part of the inspection and varied in the quality of information provided. Details of other health care professionals involved with the residents’ care were not recorded. One care plan was being monitored monthly to ensure that the residents’ needs were being met; the other care plan had not been reviewed since February 2005. This is an outstanding requirement from the last inspection. See requirement 2 Risk assessments did not cover all aspects of the residents’ lives; staff reported that training is being planned. See requirement 3 Woodlands Lodge And Cottage DS0000006618.V260678.R01.S.doc Version 5.0 Page 10 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): None of these standards were covered as the key standards were reviewed at the last inspection EVIDENCE: Woodlands Lodge And Cottage DS0000006618.V260678.R01.S.doc Version 5.0 Page 11 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): 21 The policy and procedure regarding death is in place to protect residents and staff. EVIDENCE: There is a policy for the organisation in respect of death of a resident and a procedure for staff to follow should a resident die whilst in the home. The subject of wills and wishes has been discussed at a recent meeting with parents. Woodlands Lodge And Cottage DS0000006618.V260678.R01.S.doc Version 5.0 Page 12 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): 23 In the absence of training relating to Adult Protection residents and staff are vulnerable. EVIDENCE: Information provided from staff and the manager’s comments on the preinspection questionnaire confirmed that the staff have not received training in relation to Protection of Vulnerable Adults. This is an outstanding requirement from the last inspection. See requirement 4 Woodlands Lodge And Cottage DS0000006618.V260678.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 -30 Without a planned maintenance program the home cannot maintain a safe environment for the residents to live in. EVIDENCE: A requirement from the last inspection to fit window restrictors has been met. The new laundry has been completed and also provides a ramped access to the property. During the inspection a tour of the premises was undertaken; some areas of the home are in need of decoration and window frames need replacing or repairing before they pose a risk to the residents welfare. This is an outstanding requirement from the last inspection. See requirement 5 Woodlands Lodge And Cottage DS0000006618.V260678.R01.S.doc Version 5.0 Page 14 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 & 34 In the absence of robust recruitment processes and training for staff, residents are vulnerable EVIDENCE: Job descriptions are available for all staff. The organisation has a Training leader and staff report that there have been some improvements in the availability of training, however staff have not achieved mandatory training. See requirement 4 See requirement 1 The pre-inspection questionnaire identified that 2 staff started employment before criminal record bureau checks had been received. See requirement Woodlands Lodge And Cottage DS0000006618.V260678.R01.S.doc Version 5.0 Page 15 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 In the absence of a quality internal monitoring tool, the organisation cannot demonstrate that the performance of the service is being reviewed. EVIDENCE: Internal quality monitoring systems (Regulation 26 visits) need to be in place and ways of obtaining the views of residents, relatives and staff about the home to enable it to develop the service it provides. This is an outstanding requirement from the last inspection. See requirement 7 Woodlands Lodge And Cottage DS0000006618.V260678.R01.S.doc Version 5.0 Page 16 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 X X X 2 Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 X 2 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Woodlands Lodge And Cottage Score X X X 3 Standard No 37 38 39 40 41 42 43 Score X X 2 X X X X DS0000006618.V260678.R01.S.doc Version 5.0 Page 17 YES 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 YA5 Regulation 5 Requirement Residents must be given a written contract or statement of the terms and conditions of residence at the home. These should include information about the accomodation provided and the method of payment of their fees Care plans must be reviewed regularly and amended to reflect any changes in the residents needs. Risk assessments should be in place to minimise risk for activities that the residents are involved in. All staff must receive training on protecting people from abuse and on adult protection procedures. Plans must be drawn up for each member of staff to receive training relevant to the role they perform. Repairs or replacement windows must be included in the planned maintenance of the home The registered person must ensure that full information regarding staff (as set out in Schedule 2 of the Care Home DS0000006618.V260678.R01.S.doc Timescale for action 16/03/06 2 YA6 15 16/03/06 3 YA9 13 31/05/06 4 YA23 18 16/03/06 5 6 YA24 YA34 23 19 16/03/06 30/05/06 Woodlands Lodge And Cottage Version 5.0 Page 18 7 YA39 26 Regulation 2000) is available before they commence employment Visits to the home must be undertaken by a nominated person for the trustees at least once a month and a report produced and supplied to the Commission for Social care Inspection 16/03/06 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 YA32 Good Practice Recommendations 50 of staff should of achieved an NVQ qualification to level 2 Woodlands Lodge And Cottage DS0000006618.V260678.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 Lodge And Cottage DS0000006618.V260678.R01.S.doc Version 5.0 Page 20 - 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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