CARE HOME ADULTS 18-65
Woodlands Residential Home 51a Elm Road Thetford Norfolk IP24 3HS Lead Inspector
Mr Jerry Crehan Unannounced Inspection 15th September 2005 2:00 Woodlands Residential Home DS0000063386.V250469.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 Residential Home DS0000063386.V250469.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 Residential Home DS0000063386.V250469.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Woodlands Residential Home Address 51a Elm Road Thetford Norfolk IP24 3HS 01842 754843 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) Active Care Partnerships (Fryers) Ltd Mrs Wendy E Sargeant Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Woodlands Residential Home DS0000063386.V250469.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 3rd May 2005 Brief Description of the Service: Woodlands is a newly built care home that opened in August 2004. It is registered to provide residential care for a maximum of 8 adults with learning disabilities who may have accompanying physical disabilities.The home is situated a short distance from the town of Thetford, on the edge of a residential housing area with access to local facilities nearby including shops. The home has been purpose built to a high standard. This enables accommodation of people with a range of support needs, particularly those requiring full physical care and support.Service users living in the home access a combination of day services, including those operated by the proprietor’s in Thetford. Woodlands Residential Home DS0000063386.V250469.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 3.5 hours. Opportunity was taken to tour the premises, look at care records and policies, and talk to service users relatives and staff. All of the service users at home at the time of the inspection were spoken to. The home now accommodates a total of six service users. What the service does well: What has improved since the last inspection?
The home have clearly made good efforts to comply with the requirements and recommendations made at the last inspection. Contracts are issued to all service users or their relatives (though these should be signed), and a revised complaints procedure has been produced in both text and ‘Boardmaker’ symbols versions. Training has been on offer to address specialist service user communication requirements, and it is hoped that this will be effectively provided to all staff as soon as possible. There have been improvements to the training provided to staff in the safe handling and administration of medicines. NVQ training is on course to comfortably exceed the minimum training requirements in the Standard. Woodlands Residential Home DS0000063386.V250469.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 Residential Home DS0000063386.V250469.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 Residential Home DS0000063386.V250469.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): 4&5 The home provides the opportunity to visit the home to assess its suitability to individual needs. Individual contracts for each service user at the home do not meet the required standard. EVIDENCE: It was apparent that prospective service users have been given the opportunity to look around the home prior to any move. This process has involved several visits and overnight stays for service users, sometimes accompanied by relatives or other representatives. This practice is reflected within the home’s policies. Signed contracts (‘agreement to occupy’) were evident in service users files seen, though these had not been signed. The home has made efforts to make this information available in other formats including ‘Boardmaker’. Woodlands Residential Home DS0000063386.V250469.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 & 10 Individual needs and choices are promoted through good care planning. EVIDENCE: Care plans seen accurately reflected information gathered within assessments and provide staff with the information they need to meet individual need. Care plans also contain individual target and goal setting. Evidence of work towards achieving goals was seen as service users participated in household activities, eating and personal care tasks. Confidentiality issues are evidently understood at the home. There are secure arrangements for the storage of records. Woodlands Residential Home DS0000063386.V250469.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): 12, 13, 15, 16 The home satisfactorily caters for the lifestyle preferences of service users. Links with the community, with relatives and others are well supported. EVIDENCE: Service users at Woodlands are engaged in day care activities both on and off site. This was the situation at the time of the inspection. Day services attended by service users include those operated by the proprietor and others that are independent of the proprietor. Other activities available to service users include sailing once each week. The manager indicated that plans have been made for the home to have access to its own mini bus by November 2005. Until then it continues to use a variety of transport for community access, including public transport. Trips into the community have included pub lunches and attendance at the local community centre for bingo. Contact with relatives and friends are supported by the home. A relative spoken to at the time of the inspection confirmed this, indicating that they were able to visit the home when they wish and that they are made welcome by the home.
Woodlands Residential Home DS0000063386.V250469.R01.S.doc Version 5.0 Page 11 Rights and responsibilities are respected and recognised at the home; service users have unrestricted access to all areas except other people’s bedrooms. All bedroom doors are lockable. Staff support service users with their post individually. Woodlands Residential Home DS0000063386.V250469.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 & 21 Service users medication needs are well attended to. Appropriate policies are in place to address ageing, illness and death. EVIDENCE: There are no service users accommodated at the home who have responsibility for their own medication. Medication storage arrangements were satisfactory. It was confirmed by the home at the last inspection that care staff must now complete formal training prior to handling and administering medicines. On discussion, it was apparent that care staff are currently being provided appropriate training in the ‘safe handling of medicines’ and other accredited training. The manager indicated that following recommendation from the last inspection members of care staff are monitored and assessed for competence in medicine handling and administration as part of their formal supervision. The home has a policy on ageing and death. There have been no deaths in the home during the time it has been open. The home has plans to consult with local services for support in the event of deterioration in the health of any service user living at the home, in order that they may remain there. Woodlands Residential Home DS0000063386.V250469.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 There are arrangements for responding to the concerns of service users that are satisfactory. EVIDENCE: The home has a newly revised complaints procedure that is available in text and using ‘Boardmaker’ symbols. The home has not received any complaints. Woodlands Residential Home DS0000063386.V250469.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 A comfortable, accessible and safe standard of accommodation is provided, both internally and externally. EVIDENCE: The home provides a homely, comfortable and safe environment for service users, with now six out of a potential eight service users accommodated. The home is kept very clean; there are good practices (and appropriate policies) to maintain hygiene. The home is free from offensive odours throughout. Woodlands Residential Home DS0000063386.V250469.R01.S.doc Version 5.0 Page 15 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 Staff at the home are well supported and employed in sufficient numbers to meet the service users needs. Staff training does not fully address the service user needs. EVIDENCE: Staff rotas indicate the deployment of sufficient staff to meet service user need. There is a core group of twelve care staff at the home, supported and overseen by the registered manager. The staff team are effectively supported and supervised. A requirement made at the last inspection to address service users specialist communication needs is being satisfactorily addressed through training for a staff member who will have responsibility for training colleagues on the completion of the training. It is apparent that service users needs arising from challenging behaviour and sensory impairment also require addressing through staff training. There are currently seven staff undertaking NVQ level 2, and a further three staff hoping to undertake NVQ level 3 training. A further staff member has completed specialist training to NVQ level 2 equivalent. Woodlands Residential Home DS0000063386.V250469.R01.S.doc Version 5.0 Page 16 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 & 40 The home is well run by an experienced, and qualified registered manager. Service users are supported by appropriate policies, procedures and record keeping. EVIDENCE: Service users communication throughout the inspection suggests that they are satisfied with the way the home is run, and have confidence in the staff and manager. The registered manager has several years’ management/supervisory experience within similar care settings, and has achieved the Registered Managers Award. Staff spoken to found the manager’s management style supportive. A range of appropriate policies and procedures has been developed, and continues to be developed by the home and the proprietor to satisfactorily safeguard service users. Woodlands Residential Home DS0000063386.V250469.R01.S.doc Version 5.0 Page 17 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 3 2 Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X X 3 Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 3 X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Woodlands Residential Home Score X X 3 3 Standard No 37 38 39 40 41 42 43 Score 3 X X 3 X X X DS0000063386.V250469.R01.S.doc Version 5.0 Page 18 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 YA32 Regulation 18(1)(c) Requirement The Registered Person must ensure that staff have the sensory impairment and challenging behaviour training appropriate to the work they are to perform. Timescale for action 31/01/06 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 32 Refer to Standard YA5 YA32 Good Practice Recommendations It is recommended that service user contracts are signed. It is recommended that the Registered Provider ensure continued progress toward meeting the 50 requirement by 2005. Woodlands Residential Home DS0000063386.V250469.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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