Inspection on 20/03/07 for Woodlands Villa

This inspection was carried out on 20th March 2007.

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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodlands Villa 19/12/07

Woodlands Villa 01/11/05

Woodlands Villa 17/02/05

Woodlands Villa 16/01/05

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

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

CARE HOME ADULTS 18-65 Woodlands Villa 496 Loose Road Maidstone Kent ME159UF Lead Inspector Michele Etherton Key Unannounced Inspection 20th March 2007 09:40 Woodlands Villa DS0000024084.V320847.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 Villa DS0000024084.V320847.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 Villa DS0000024084.V320847.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Villa Address 496 Loose Road Maidstone Kent ME159UF 01622 746295 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Ellen Rose Russell Mrs Ellen Rose Russell Care Home 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (13) of places Woodlands Villa DS0000024084.V320847.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 older person with a mental disorder whose date of birth 27/08/1934 Date of last inspection 1st November 2005 Brief Description of the Service: Woodlands Villa is a large detached property with accommodation on two floors for 10 service users covering an age range of 21 to 71, who have mental health difficulties. The home is a family run enterprise with the provider/manager and members of the immediate family supplementing the staffing within the home in addition to five employed members of staff. The home has recently increased its registration to 13 by the proposed change of use of provider living quarters, however implementation of these additional bed spaces is still to take place, and numbers currently remain at 10. The increase in bed spaces will bring single rooms up to 9 with 2-shared rooms. At present some members of the provider’s family who work within the home live on site. The kitchen and laundry are shared between family members and residents. The ethos of the home actively encourages development of independence and practical daily living skills. There is an expectation that service users will participate in the daily routines of the house and undertake household tasks. 24-hour staff cover is provided with a minimum of two staff on duty for daytime shifts. The home has one waking night and one sleep in member of staff for the night shift. There is a garden to the rear of the house, which service users can use. The home is located approximately 1½ miles from Maidstone town centre. There are shops, pub and a church within walking distance. There is a bus stop outside the house and car parking is available to the front of the property. A copy of the inspection report can be reviewed on request at the home. Fees for the service range between £493.63 and £800.00 per week dependent on assessed needs. A separate fee structure exists for those funded through the local authority. Woodlands Villa DS0000024084.V320847.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of this service has taken account of feedback from service users during the site visit and limited responses from health and social care professionals gained post visit. Unfortunately pre-inspection information was not available for the home and no feedback was received from relatives. An unannounced site visit of the home was undertaken on 20th March 2007. The site visit commenced at 9:40 a.m. and finished at 15:20 p.m. The site visit comprised time spent speaking with service users, and staff members, the deputy manager and the provider/manager. A tour of the premises was undertaken in the company of a service user. A review of some sample documentation including user plans, health and medication records, staff personnel and training records, accident reports, the fire book, food records, equipment and servicing records etc was also undertaken. All key standards were assessed in addition to those where previous requirements and recommendations have been issued. Although other standards were not assessed in full, where shortfalls in those standards became evident during the course of the site visit, these findings have also been incorporated into the report and contributed to the quality ratings. The home has a current adult protection alert open and has been proactive in reporting concerns to the adult protection co-ordinator, an outcome of the current investigation is awaited. What the service does well: The home is family run and provides a stable and consistent level of support to service users from a familiar core team of staff. Accommodation is provided in a non-institutional domestic style setting and is maintained to a good standard. Admissions to the home are undertaken at a pace that individual prospective service users can cope with and involve introductory visits and stays. Service users like the family orientated atmosphere of the home and enjoy having family members living on site. The service actively promotes and supports the development of practical daily living skills and the independence of service users. Woodlands Villa DS0000024084.V320847.R01.S.doc Version 5.2 Page 6 The service communicates well with professionals and is open and responsive to advice and guidance. “staff understand service users’ needs and sometimes go to extra lengths in supporting them” The home supports and facilitates opportunities for service users to access the community, make use of leisure activities, and maintain contacts with families and friends. The home demonstrates a commitment to staff training. Staff feel well supported. What has improved since the last inspection? What they could do better: The service generally provides good outcomes for service users and ensures service users are at the centre of service provision however, shortfalls in required documentation and record keeping that support and evidence practice and a responsible approach to risk taking are inadequate. This impacts on the overall quality rating for the home; requirements have been issued for these to be addressed. The Statement of Purpose and Service User Guide have been reviewed to take account of changes to the service, but some further clarification is required around whether users can remain at the home beyond the age of 65 and the homes ability to support people with dual diagnosis. Risk assessments in relation to self or partial medication and consents to medication are not routinely provided. Record keeping in relation to staff recruitment, training and supervision is not routinely maintained and updated. A number of good practice recommendations have also been made for the home to clearly evidence information they have gained through assessment visits that inform decision-making. That any restrictions within daily routines are clearly recorded in support plans. Current medication arrangements would Woodlands Villa DS0000024084.V320847.R01.S.doc Version 5.2 Page 7 be enhanced by the introduction of individual medication profiles and PRN medication guidelines to inform staff. The home needs to review current staff sleep in arrangements and their impact on service users. Minor upgrading to a downstairs shower room and the introduction of paper hand towels will provide additional support to infection control measures. The home understands the need to develop quality assurance processes and should take steps to develop quality monitoring and self audit systems to assess overall service quality. The home should ensure that policies and procedures are routinely reviewed with reference to changes in legislation and guidance around best practice. 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 Villa DS0000024084.V320847.R01.S.doc Version 5.2 Page 8 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 Villa DS0000024084.V320847.R01.S.doc Version 5.2 Page 9 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): 1,2,3,4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home should ensure that information available to people using the service fully reflects the service offered. Service users can be confident that their needs will be assessed to ensure needs can be met and that they will be provided with opportunities to visit the home before admission. EVIDENCE: There has been a recent increase in numbers of service users the home is registered for owing to the planned re-use of existing provider accommodation. This change has not been implemented and family members continue to live onsite. The home offers a service to people with mental health problems other than those with a learning disability or dementia, however, the home has taken people with dual diagnosis and will continue to offer a service to those living in the home beyond their 65th birthday. As a consequence this should be appropriately reflected within the statement of purpose. The home is required to ensure that changes to the service offered by the home are fully reflected in information made available to prospective users and their representatives. Woodlands Villa DS0000024084.V320847.R01.S.doc Version 5.2 Page 10 Assessment of prospective service users is undertaken by health and social care professionals and copies of this information is made available to the home. The provider and other family members undertake to visit prospective service users. Records of these visits are inconsistently recorded; as this information supplements professional assessments and aids decision-making around admission, it is recommended that this should be more clearly and consistently evidenced. The provider advised that a key factor in making decisions regarding admission is the willingness of prospective users to come to the home and to respect and value the other service users and the staff. The provider and other staff members demonstrated an awareness of the limitations of the service in respect of some service users’ changing needs. Health and Social Care professionals reported that the home communicates well with all agencies and acts appropriately in seeking interventions where care needs are becoming increasingly difficult to manage. Prospective service users are provided with opportunities to visit the home for short visits and overnights stays prior to admission. The admission process is tailored to the individual pace of the prospective service user and it can take up to two months for an admission to take place. Woodlands Villa DS0000024084.V320847.R01.S.doc Version 5.2 Page 11 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): 6,7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ personal goals and routines are reflected in their care plans. They are encouraged to make decisions and make choices about participation in household routines and external activities. Service users are supported to take responsible risks. EVIDENCE: Individual plans of care are in place, they contain satisfactory detail around routines and support. Those viewed provided evidence of updating. Health and social care professionals who were consulted, expressed the view that specialist advice and guidance is incorporated into the support plans appropriately. The provider expressed the view that it was important to prepare service users for living in the community. To support this the home actively promotes independence and the development and maintenance of daily living skills for all service users. There is an expectation that they will undertake household Woodlands Villa DS0000024084.V320847.R01.S.doc Version 5.2 Page 12 tasks and take responsibility for their own daily routines. Service users spoken with confirmed their chores and responsibilities for daily routines. One service user was observed undertaking personal laundry tasks and another confirmed they were cooking the main meal that evening with staff support. “I help with the cleaning, and I go to visit my relative in Essex, I use the bus to get there.” “I enjoy living here, I go out quite a bit during the week, I’ve got plenty to do” Health and Social Care professionals spoken with indicated that in their view the home offers a good service that is “very caring” of the service users. “Staff demonstrate an understanding of the care needs of service users and at times go to extra lengths to support users”. Some concerns were expressed that the caring family oriented ethos of the home, whilst positive, creates for some service users, a dependency that inhibits their ability to move on. It is considered that improved objectivity and establishment of boundaries by home staff, will improve this process. This is already being worked on with some senior staff and should be cascaded to the whole staff team to ensure consistency. “Staff do not always understand how to deal with service users’ behaviour that challenges and would benefit from additional training” Service users are enabled to take responsible risks and these are discussed amongst the staff team and with the service user concerned, life skills are reassessed on a quarterly basis. Woodlands Villa DS0000024084.V320847.R01.S.doc Version 5.2 Page 13 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): 11,12,13,14,15,16,17, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users lead active lifestyles and are encouraged to participate in the running of the home. They are supported to develop and maintain relationships. Restrictions within daily routines need to be clearly evidenced within support plans. EVIDENCE: Through discussion with and observation of service users it became evident that most enjoy a varied and active lifestyle. All have individual responsibilities to undertake household tasks e.g. cleaning their bedroom, doing their own laundry and ironing. They participate in activities in the community including in one case, a work placement and paper round, and for others attendance at various centres and activities in the Maidstone area. All service users make use of public transport and are independent travellers, the home will undertake some route orientation when users are first admitted to ensure familiarisation with bus routes. Woodlands Villa DS0000024084.V320847.R01.S.doc Version 5.2 Page 14 Two service users spoken with confirmed visits to and from family members. Another service user spoke of how they enjoyed a holiday to Butlins with other service users and a staff member, and also a break at Christmas at a hotel on the coast. There are plans for a further holiday in the summer and service users are looking forward to this. The atmosphere within the home was observed to be relaxed and friendly; service users interacted well with each other and staff. Bedrooms viewed had locks on doors but only one service user currently has a key. Two residents spoken with indicated they would like a key to their individual rooms, they commented: “I think it would be nice to keep your things private”, “Yes I would like to be able to lock the door when I go out”. The home should reconsider the provision of keys to service users taking account of their capacity and likely risks. Where a key is not provided or other restrictions are in place this should be clearly recorded within care plans and or behaviour guidelines and agreed by the service user concerned and involved Professionals etc; this is a recommendation. Discussions with service users indicated general satisfaction with meal arrangements, service users are fully consulted about the main meal and take turns in preparing and serving it. Service users confirmed they make their own breakfast and were observed making drinks during the course of the site visit. Service users and staff eat together for the evening meal. A service user confirmed that they can access the kitchen into late in the evening for snacks etc, and that users are responsible for cleaning up after themselves. The home maintains good records of meals provided and food eaten; this indicates a variety of well-balanced meals using fresh produce in most cases. Woodlands Villa DS0000024084.V320847.R01.S.doc Version 5.2 Page 15 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): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The privacy and dignity of service users is promoted by their taking control of their own daily routines in their preferred manner, their health care is supported and maintained. Arrangements for the administration and recording of medication need development in keeping with current good practice guidance. EVIDENCE: Discussion with service users and staff indicated that the majority of service users undertake their own personal care routines, this may on occasion require some additional prompting or supervision by staff if users are experiencing periods of being unwell. Some service users spoken with confirmed access to GP’s and routine dental and optician appointments, user records viewed confirmed some specialist appointments. Staff reported that chiropody is offered to those who need it. The provider highlighted the need at times to advocate on behalf of some residents where inequality of access to health services etc had arisen. Service Woodlands Villa DS0000024084.V320847.R01.S.doc Version 5.2 Page 16 users are weighed monthly, where this is particularly important this support is clearly highlighted within the care plan. Discussion indicated that the home actively seeks reviews of medication for some service users where they feel this would benefit the service user. The home has not reviewed its medication procedure for some time and this needs to be undertaken with a view to looking at current guidance around best practice in the administration of medication. MAR charts are in place and were completed satisfactorily; consideration should be given to improving clarity by the inclusion of separators between sheets with user photos. Administering staff are trained in medication Medication risk assessment information is not clearly evidenced for those who undertake partial administration or self-administration. Consents to medication were not noted in user files viewed. The home is required to address these shortfalls within current medication arrangements. Woodlands Villa DS0000024084.V320847.R01.S.doc Version 5.2 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. Service users feel listened to and know that their views will be acted upon. Policies and procedures are in place at the home however, these do not fully protect service users. EVIDENCE: The provider reported that no complaints have been received since the last inspection. Service users spoken with said that they would speak with staff or in one case their mother if they were unhappy with things. There are good systems in place for service users to express their views and some service users receive 1-1 sessions to deal with specific issues. Resident meetings would also provide opportunities for users to meet staff and express concerns. Most have access to other professionals outside of the home and could also raise concerns in those forums. The provider is a trained trainer in adult protection and staff receive the necessary training. Discussion with the provider and staff indicated an awareness of abuse and this is appropriately reported where concerns arise. An adult protection alert was raised and closed last year, there were no outcomes for the home to follow up on. Another adult protection alert has recently been raised appropriately by the home with the adult protection coordinator and an outcome on this is still awaited. Discussion with the provider indicated that there has been at least one occasion where a service user has exhibited extreme violence towards a Woodlands Villa DS0000024084.V320847.R01.S.doc Version 5.2 Page 18 member of the staff team, whilst this was unusual, discussions with staff indicated that they would in such cases try to de-escalate the situation and remove other users safety. Although the home has experience of behaviour monitoring it is recommended that they consider the development of behaviour management guidelines for those users who challenge the service, these should be undertaken with appropriate professionals and the service user concerned. Woodlands Villa DS0000024084.V320847.R01.S.doc Version 5.2 Page 19 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): 24,25,26,27,28,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a comfortable, homely and clean environment that meets their needs but this would benefit from some improvements. EVIDENCE: The home is maintained to a good standard. Users bedrooms are highly personalised with service users able to express their personal tastes and interests. Shared rooms have appropriate screening in place, service users who share reported that they were happy to do so and enjoyed the company. There are two user lounges, one is a quiet room and there is also a conservatory. The quiet room is off limits in the evenings after 8.30 pm as it is used as a staff sleep in area, service users stated this was on the floor not on the settees. Those spoken with did not find this impacted on them or restricted them in any way at present. The home are responsible for providing appropriate sleep in accommodation for staff and should consider ways of Woodlands Villa DS0000024084.V320847.R01.S.doc Version 5.2 Page 20 doing so in another part of the home that does not compromise user space this is a recommendation. Communal spaces comfortably furnished and décor is in good order, however, with so many staff training certificates displayed in communal areas there is a danger of this bringing a more institutional look to the home, although when asked about them during the visit service users reported that they were not particularly bothered by the certificates. The home should review the appropriateness of displaying staff training certificates in what is essentially the service users’ home. The downstairs shower room is in need of upgrade around the sink area, with cracked and peeling paint that could pose a problem of cross infection. It was noticeable that paper hand towels are not routinely provided in hand wash areas and a cloth towel is usually provided, consideration should be given to provision of paper towels to support infection control measures within the house. The home is recommended to address these shortfalls. Service users undertake their own laundry and appropriate facilities are provided for this. The home has a stair lift that is not currently used, but has been retained for the use of older service users and those with reduced mobility, as it is needed. The home has addressed an outstanding requirement and a new fire risk assessment was completed in November 2006, the provider has advised that recommendations from that assessment have been implemented. There is a neat garden laid to lawn in the rear with benches and garden furniture, clients were observed hanging their laundry out on the line, and one spoke of going out in the garden in good weather. Woodlands Villa DS0000024084.V320847.R01.S.doc Version 5.2 Page 21 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): 32,34,35,36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is still to achieve expected standards of qualified staff. Staff confidence in dealing with some behaviour could be improved by access to more specialised training. The home management team should ensure it has a full understanding of all current legislation and guidance in relation to recruitment and induction of staff. The home should evidence clearly records of formal supervisions carried out with staff. EVIDENCE: The home is able to demonstrate a clear commitment to the training of staff but is still to achieve the expected standard of qualified staff, and should continue to encourage all staff to undertake NVQ training, this remains an outstanding recommendation. The home has been fortunate to retain a loyal team of staff over a number of years that has meant no recruitment has needed to take place. Staff spoken with felt well supported and found the provider and other family members approachable and accessible at all times. “ feel well supported and find the family approachable” Woodlands Villa DS0000024084.V320847.R01.S.doc Version 5.2 Page 22 “ I feel this user group creates more stress than elders, but I never feel threatened and am confident of managing situations”. A sample of personnel files relating to two staff indicated some shortfalls in the required content of staff personnel files to evidence a robust recruitment procedure have taken place. The home are planning to recruit in the near future and are keen to ensure this is done in full compliance with regulations and the NMS. Discussion during the site visit ensured that a fuller understanding of what is expected was reached with the provider and will be implemented in future. Personnel files viewed provided evidence of an initial induction for the staff concerned. This type of induction is no longer sufficient and the provider was reminded that any new staff that may be recruited in the near future must receive induction in keeping with Skills for Care induction standards and they will need to familiarise themselves with this and the materials used with new staff to assess competency. Individual staff training profiles were in place but not updated to reflect actual training achieved by staff. The home would benefit from the development of a staff training matrix. Health and Social Care professionals consulted post site visit expressed the view that whilst all staff worked well with service users they would benefit from additional mental health training particularly around working with service users who may challenge the service e.g. refusal to medicate, self neglect, non participation, areas that they experience most difficulty in working with service users. The home should consider this within the programme of training for staff. Although not a key standard it became evident whilst reviewing staff files that records of supervision were more than a year out of date. Staff spoken with reported that they were in receipt of supervision from a senior staff member, but, were unclear on the frequency of these. Staff indicated that they found the management team accessible and approachable at any time and felt supported by them and able to discuss issues with them. Woodlands Villa DS0000024084.V320847.R01.S.doc Version 5.2 Page 23 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): 37,39,41,42,43 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally well run primarily in the interests of the service users. Quality assurance systems and evidence of self assessment of service quality need further development. The updating of policies and procedures and quality of some record keeping needs improvement. EVIDENCE: The service continues to be family run, with various family members taking roles within the staff team. The provider /manager has not pursued NVQ4 or registered manager training in view of plans for retirement. There are plans for the current deputy manager and daughter of the provider to take on the role of manager with ongoing support from the other family members. Woodlands Villa DS0000024084.V320847.R01.S.doc Version 5.2 Page 24 The current provider/manager has attended relevant training in relation to the direct support of service users and is clearly aware of some of the changes in recent legislation including the mental capacity Act 2005 and will be seeking training in this area. The home is proactive in addressing requirements issued at inspection. Health and Social Care professionals report that the home is open and responsive to receiving advice and guidance in relation to the support provided to service users in their care and incorporating this into support plans. There is a very supportive and caring atmosphere within the home, that enables service users to develop daily routines and practical skills at their own pace and level. Residents interact well together and there is a real sense of mutual respect and understanding of each other and staff. Residents are asked for their views about the service through questionnaires and user meetings. Currently the home does not produce a report analysing user feedback or how this influences service development. A previous recommendation to seek the views of professionals has not been implemented nor are there currently systems in place for the home to self assess and quality monitor its own service. These areas were fully discussed with the provider during the site visit and a recommendation made that the home develop quality assurance systems to monitor and self assess service quality and also to broaden the consultation with users to include other stakeholder groups. Policies and procedures are not routinely being reviewed in line with changes to legislation and guidance, although the home could evidence that new policy and procedures are developed in response to service needs. Whilst records relating to the health and care needs of service users are well maintained and the home has partially implemented a previous recommendation for the inclusion of photographs on user and staff records, generally those relating to staff recruitment, training and supervision need attention, and the home are required to address these shortfalls. Staff are provided with health and safety training. The provider confirmed that all necessary servicing of equipment and services has been undertaken and samples of servicing certificates and invoices for gas, electrical installation and electrical equipment, fire alarm, extinguishers etc were noted. A fire book is maintained and records appropriate testing of call points and fire drills, for staff. The home has implemented a previous requirement to ensure staff fire drills are undertaken routinely and records maintained of these. Woodlands Villa DS0000024084.V320847.R01.S.doc Version 5.2 Page 25 There is a low level of accidents amongst staff and residents, the home has adopted a Health & Safety Executive approved recording format and are filing reports away as required. Although not a key standard and not assessed in full, it became evident during the site visit that in keeping with standard 43, a current insurance certificate for the home was out of date. This was discussed with the provider who assured us that a current insurance policy has been obtained but is not currently on display and was not available to view. The provider agreed to ensure the updated policy is displayed. Woodlands Villa DS0000024084.V320847.R01.S.doc Version 5.2 Page 26 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 2 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 2 26 2 27 3 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 2 2 3 2 Woodlands Villa DS0000024084.V320847.R01.S.doc Version 5.2 Page 27 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 YA1 Regulation 4 &5 Requirement Timescale for action 20/05/07 2 YA20 13(2) 3 YA41 17 The home must ensure that the Statement of Purpose and user guide information are kept updated to reflect changes within the service. The home must ensure the 20/05/07 medication procedure is reviewed in line with current guidance. Evidence of risk assessment in respect of partial or full self-medication by service users. Medication consents should be clearly evidenced within user files with review dates The home must ensure that it 20/05/07 routinely updates and maintains all required records. Woodlands Villa DS0000024084.V320847.R01.S.doc Version 5.2 Page 28 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 YA2 Good Practice Recommendations Home should evidence clearly information gained during assessment visits that informs decisions around admission and development of support plans Restrictions around provision of keys to bedrooms, smoking etc need to be clearly evidenced within user plans. User support plans would benefit from the development of individual Medication profiles and PRN guidelines. The development of Behaviour guidelines for those service users who challenge the service would aid staff in providing a consistent support in keeping with advice from professionals. The home should review current staff sleep in arrangements. Infection control measures would be improved by the provision of Paper hand towels in wash areas, and an upgrade of the sink area of downstairs shower room. Systems for undertaking quality monitoring and selfassessment of service quality need to be developed. Broader consultation about service quality that includes professionals should be implemented. Analysis of feedback and how this influences service development should be reported on. The home should routinely review and update policies and procedures to support staff practice. 2 3 4 YA16 YA20 YA23 5 6 7 YA28 YA30 YA39 8 YA40 Woodlands Villa DS0000024084.V320847.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Villa DS0000024084.V320847.R01.S.doc Version 5.2 Page 30 - 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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