Inspection on 03/05/05 for Woodlands Residential Home

This inspection was carried out on 3rd May 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 but made no statutory requirements on the home.

Other inspections for this house

Woodlands Residential Home 23/08/07

Woodlands Residential Home 04/01/07

Woodlands Residential Home 15/09/05

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Woodlands Residential Home 51a Elm Road Thetford Norfolk IP24 3HS Lead Inspector Jerry Crehan Announced 3 May 2005 rd 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 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 Stationary 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 I55s63386woodlandsv217100030505(4).doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Woodlands Residential Home Address 51a Elm Road, Thetford, Norfolk, IP24 3HS Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01325 351100 Active Care Partnerships (Fryers) Ltd Mrs Wendy E Sargeant Care Home 8 Category(ies) of Leaning Disability (8) registration, with number of places Woodlands Residential Home I55s63386woodlandsv217100030505(4).doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The home can accommodate up to 8 adults of either sex who will have learning disabilities, and who may have accompanying physical disabilities. Date of last inspection 16th December 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 I55s63386woodlandsv217100030505(4).doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s first announced inspection since its registration in August 2004. The inspection took place over 6 hours. Opportunity was taken to tour the premises, look at care records and policies, and communicate with each of the three service users and with four members of care staff in addition to the registered manager. Two comment cards were received from relatives of service users indicating satisfaction with the care provided at the home. What the service does well: What has improved since the last inspection? What they could do better: Woodlands Residential Home I55s63386woodlandsv217100030505(4).doc Version 1.30 Page 6 Further work and staff training will be required to adequately address service user communication requirements. At present there is no specific or generalised communication training on offer to staff. Thought needs to be given to how to meet the diverse communication needs of the service user group. The further development of measures to ensure that the views of service users underpin all aspects of the home’s review, development and self-monitoring. This will ensure that the home continues to provide the service desired and needed by service users. 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 I55s63386woodlandsv217100030505(4).doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Woodlands Residential Home I55s63386woodlandsv217100030505(4).doc Version 1.30 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 standard(s) 1,2,5 The information and admission process is effective, ensuring that there is a proper assessment prior to service users moving into the home. Some progress has been made in developing contracts, though service users still lack the protection a contract provides. EVIDENCE: Woodlands provides clear information that would enable prospective service users to make an informed choice as to whether and how the home could meet their needs. Information can be made available in other formats to suit individual communication requirements. An example of this was service information in a symbol format called ‘Boardmaker’. Detailed assessments were seen which evidence the completion of prospective service users aspirations and needs. Signed contracts (‘agreement to occupy’) were not evident in service users files seen. However, it was apparent that the home was liaising with placing authorities to ensure their contracts were in place. Woodlands Residential Home I55s63386woodlandsv217100030505(4).doc Version 1.30 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 standard(s) 6,7,8,9 There is a clear and consistent care planning system in place that enables service users to participate in aspects of life. Independence is promoted through good care planning and assessment of risk. 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. Individual risk assessments are undertaken at the home to support the independence of service users. Risk assessments seen addressed issues arising from service users assessed needs and care plans. It was evident that service users are supported in making decisions about aspects of life within the home. Staff were observed in supporting service users to make decisions and choices by presenting a range of options available. Woodlands Residential Home I55s63386woodlandsv217100030505(4).doc Version 1.30 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 standard(s) 17 Meals at the home are good offering choice and variety according to preference, and catering for special dietary needs. EVIDENCE: Care staff prepare meals at the home (though service users have the opportunity to prepare food with support too). The main meal served at the time of the inspection looked healthy, appetising and contained fresh produce. It was evident that menu setting was a joint activity, and based on individual preferences. Low fat or healthy eating options were available to meet individual need, and specially prepared meals seen. Woodlands Residential Home I55s63386woodlandsv217100030505(4).doc Version 1.30 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 standard(s) 18,19,20 The systems for providing service user personal healthcare support are reasonable and in the process of improvement and review. EVIDENCE: Service users care plans seen contained clear information as to where personal support was required, and how it should be delivered. A specific plan concerning the management of a service users epilepsy, including the administration of an appropriate medication was reviewed. The plan was clear as to what (and when) actions should be undertaken by staff. However, did not correspond accurately with the accompanying risk assessment, and may not therefore meet the health needs of the service user. Further advice was given that the plan more accurately reflect the operational practice of the home, and that further advice be taken from appropriate health professional as to the latest safe practice guidance. There are no service users accommodated at the home who have responsibility for their own medication. On review of medication records one discrepancy was identified. Otherwise records and storage arrangements were satisfactory. It was confirmed by the home that care staff must now complete formal training prior to handling and administering medicines. On discussion, it was recommended that the home’s medicine policy document is provided for all members of care staff authorised to handle and administer medicines to read, acknowledge and adhere to at all times. Woodlands Residential Home I55s63386woodlandsv217100030505(4).doc Version 1.30 Page 12 Woodlands Residential Home I55s63386woodlandsv217100030505(4).doc Version 1.30 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 standard(s) 22,23 The home has a complaints system in place that is partly, but not fully satisfactory. EVIDENCE: The home has a detailed complaints procedure, but had not received any complaints. The complaints procedure seen appears in the form of procedural advice for staff, and not information for service users, their relatives or others. It is not therefore clear whether service users (or others) would feel that their views would be listened to and acted on. However, a revised complaints procedure has recently been developed using ‘Boardmaker’ symbols. A procedure for responding to allegations of abuse is in place. Staff spoken to appeared aware of the procedure and its function, and had received appropriate training. Woodlands Residential Home I55s63386woodlandsv217100030505(4).doc Version 1.30 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 standard(s) 24,25,26,27,28,29,30 The home is well equipped to meet the needs of its service users and provides an excellent standard of accommodation. EVIDENCE: The home provides a homely, comfortable and safe environment for service users, albeit that only three out of a potential eight service users are accommodated. The interior is unobstructed, is well decorated and furnished to a very high standard and appropriately to the needs of service users. Individual rooms are evidently personalised to reflect individual tastes. It is apparent that relatives have been able to support service users and the home in this. Toilets and bathrooms are specially adapted to meet individual needs, and every bedroom has en-suite toilet and wash-hand basin. There are a variety of communal spaces within the home that provide for a different ambience. The garden area has a patio, and there are plans for further development. There are beneficial links established between the home with relatives of service users, who have been active in improving the garden area. Woodlands Residential Home I55s63386woodlandsv217100030505(4).doc Version 1.30 Page 15 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 I55s63386woodlandsv217100030505(4).doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35,36 Staff at the home are well supported and employed in sufficient needs to meet the service users needs. Staff training does not fully address the service user needs. EVIDENCE: Staff spoken to were clear about their roles and responsibilities and confirmed that they had been issues with job descriptions. Job descriptions seen were appropriate to the needs of service users at the home. Staff files looked at showed that service users are protected by good recruitment practices. An effective staff team, who are well supported and supervised supports service users. Service users benefit from staff access to a variety of appropriate training. However, it is not clear that the staff group is adequately addressing service users communication requirements. There is no specific communication training on offer to staff, and service users individual and joint communication needs are very varied. There is currently only one NVQ 2 trained member of staff. However, it was apparent that a further six staff were hoping to undertake the NVQ programme. Woodlands Residential Home I55s63386woodlandsv217100030505(4).doc Version 1.30 Page 17 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38,39,41,42 The manager provides clear leadership and is well supported by the staff team. The systems for service user consultation are good with evidence that service users are supported to express views. EVIDENCE: It was apparent that service users and staff have respect for, and confidence in the manager. Comment cards received from the relatives of two service users further support this. The views of service users are clearly sought on every day issues associated with the running of the home, though not necessarily on the development of policies and procedures. The home demonstrated good record keeping practices ensuring service users confidentiality. Relevant health and safety training for staff was in evidence to promote the health and safety of service users. This includes moving and handling, first aid, fire and food hygiene training. Woodlands Residential Home I55s63386woodlandsv217100030505(4).doc Version 1.30 Page 18 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 3 3 x x 2 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 x x x x x x 3 Standard No 31 32 33 34 35 36 Score 3 2 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Woodlands Residential Home Score 3 2 2 x Standard No 37 38 39 40 41 42 43 Score x 3 3 x 3 3 x I55s63386woodlandsv217100030505(4).doc Version 1.30 Page 19 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 5 Regulation 5.2 Requirement The Registered Person must ensure that terms and conditions of residence are developed with each service user incorporating all of the information required in Standard 5.2.(Previous timescale of February 2005 not met). The Registered Person must ensure that the home closely monitors its risk assessments, with relevant professionals, in respect of service users. The Registered Person must ensure that staff have the specialist communication skills to meet service user need. Timescale for action 30 June 2005 2. 19 13(4)(c ) Immediate and Ongoing 30 September 2005 3. 32 18(1)(c.) 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 20 Good Practice Recommendations It is recommended that completed medicine policy documentation is provided for all members of care staff authorised to handle and administer medicines to read, acknowledge and adhere to at all times. It is recommended that following training, members of I55s63386woodlandsv217100030505(4).doc Version 1.30 Page 20 2. 20 Woodlands Residential Home 3. 22 4. 5. 32 39 care staff are monitored and assessed for competence in medicine handling and administration on a regular basis as part of their formal supervision. It is recommended that that the complaints procedure for service users should be revised to ensure that it is clear about its audience and purpose and is directed to service users (e.g. by using “you”, and “your” complaint). It is recommended that the Registered Provider ensure continued progress toward meeting the 50 requirement by 2005. It is recommended that the home further develops service user input into quality monitoring to include the development of policies and procedures. Woodlands Residential Home I55s63386woodlandsv217100030505(4).doc Version 1.30 Page 21 Commission for Social Care Inspection 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 © 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 Residential Home I55s63386woodlandsv217100030505(4).doc Version 1.30 Page 22 - 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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