Inspection on 19/05/06 for Woodlarks Workshop

This inspection was carried out on 19th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 21 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodlarks Workshop 06/12/07

Woodlarks Workshop 13/03/07

Woodlarks Workshop 30/08/05

Woodlarks Workshop 04/05/05

Woodlarks Workshop 09/12/04

Woodlarks Workshop 15/06/04

Similar services:

Thorndene

Sutton Lodge Nursing Home

Wingham Court

Bethany Lodge

17 John Street

Red Oaks

Clare House Nursing Home

Broad Oak Manor Nursing Home

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

CARE HOME ADULTS 18-65 Woodlarks Workshop Lodge Hill Road Farnham Surrey GU10 3RB Lead Inspector Vera Bulbeck Unannounced Inspection 19th May 2006 09:30 Woodlarks Workshop DS0000013841.V291581.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 Woodlarks Workshop DS0000013841.V291581.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. Woodlarks Workshop DS0000013841.V291581.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlarks Workshop Address Lodge Hill Road Farnham Surrey GU10 3RB 01252 714041 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) Woodlarks Workshop Trust Mrs Moira Joan Woodage Care Home 22 Category(ies) of Physical disability (18), Physical disability over registration, with number 65 years of age (4), Sensory impairment (1) of places Woodlarks Workshop DS0000013841.V291581.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: 18 RESIDENTS WITHIN THE AGE RANGE OF 18 - 64 YEARS & 4 RESIDENTS 65 YEARS & OVER One service user with a sensory impairment Date of last inspection 30th August 2005 Brief Description of the Service: Woodlarks Workshop is a care home offering personal care for people with physical disabilities who are mostly below the age of 65 years. The purpose of Woodlarks Workshop is to provide opportunities for service users to develop personal and independent skills in a setting where their social and emotional needs are met in a safe and supportive environment. The sheltered workshop facility is pivotal to the daily activities for service users, and the service additionally offers respite care. Communal lounges are light and spacious and there is a dining area where meals are served in two sittings. Bedroom accommodation is in single rooms. All have a designated living area, facilities for making drinks, a private telephone and a lockable storage facility. The building is on three levels served by two passenger lifts. The design of the environment is suitable to meet the specific needs of the service user group, many of whom have lived at Woodlarks for many years. There is a small gymnasium used for physiotherapy sessions and personal exercise. Woodlarks Workshop is situated in a semi rural location on the outskirts of Farnham, surrounded by well-maintained spacious grounds. Local shops and community amenities are within a short distance by car, and the home is accessible by rail, the station being located in the town. Woodlarks Workshop DS0000013841.V291581.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first site visit to be undertaken by the Commission for Social Care Inspection year April 2006 to March 2007. Mrs Vera Bulbeck, Regulation Inspector, carried out the inspection. Mrs Moira Woodage the registered manager for the home was present. The inspection was undertaken over 8 hours and 30 minutes. There are currently twenty-one residents living in the home, and the majority have lived in the home for some considerable time. All the residents were in the workshop and work environments on the day of the site visit; and the inspector was able to speak with three of the residents during the tour of the premises and later in the afternoon a further four residents. The majority of staff on duty on the day of the inspection was spoken to and one member of staff commented the home is operating on an open management style and the staff team feel supported and work together as a stable team. A full tour of the premises was undertaken. Three care plans and three staff files were inspected. It was disappointing to note that six requirements from the previous inspection had not been met. As a matter of priority these requirements must be attended too. The inspector would like to thank the residents, registered manager, deputy manager and staff members for their time, assistance and hospitality during the inspection. The residents living in the home wish to be called residents, therefore service users will be referred to as residents throughout the report. A letter of serious concern has been sent to the chairman of the Trust and the registered manager, regarding cleaning materials, which were found in unlocked areas of the home, and medication prescribed for a resident was found in another resident’s bedroom. Medication must only be administered to the person prescribed for. Action to be taken immediately, to ensure the health and safety of the residents living in the home. An improvement plan must be submitted to the Commission for Social Care Inspection (CSCI) with dates and timescales regarding the requirements outstanding and requirements made at the site visit on 19/05/06. Woodlarks Workshop DS0000013841.V291581.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The home to ensure any requirements made must be addressed within the timescales given. If for any reason these are not achievable to contact the Commission for Social Care Inspection, Regulation Inspector for Woodlarks Workshop to advise the reason for non-compliance. It was disappointing to discover that a number of areas around the home are in need of attention, and a number of these areas have been carried forward previously. Management of the home should undertake a regular routine walk around the home to ensure all areas in the home are working and are safe for residents. The home also needs to have a regular visit by a responsible person to check for any areas of bad practice and to check the premises. Woodlarks Workshop DS0000013841.V291581.R01.S.doc Version 5.2 Page 7 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. Woodlarks Workshop DS0000013841.V291581.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 Woodlarks Workshop DS0000013841.V291581.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs and aspirations are fully assessed and documented prior to admission and on an ongoing basis in regular reviews. EVIDENCE: The statement of purpose, which details the service provided to residents, needs to be updated to reflect the required information as detailed in Schedule 1 of the Care Homes Regulations 2001. The service users guide also needs to be updated to contain details with regards to charges for transport and laundry. Residents are admitted to the home following a full needs assessment, which is undertaken by the manager or the deputy managers. The inspector would advise staff to ensure all areas of the form to be completed at the time of the pre assessment. Details are held on the care plan. There have not been any new residents in the home since 2005. Care plans are in the process of being updated and are now person centred planning. Woodlarks Workshop DS0000013841.V291581.R01.S.doc Version 5.2 Page 10 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, 7 and 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The residents’ individual plans, are clear and comprehensive including details of needs and goals. They also incorporate known or indicated preferences and choices, and include risk assessments. However, the staff are in the process of updating the care plans and changing from care plans to Person Centred Planning. EVIDENCE: Staff stated that residents are supported to make decisions affecting their lives in a number of ways. Each resident has an allocated key worker, who is trained to offer one to one support and who knows the resident well and understands his or her needs. Resident’s meetings are held to enable residents to make decisions and choices, for holidays, menu planning and outings. For example residents spoke of attending the meetings and notes of a meeting were seen. Resident’s individual choices of meals were recorded on the weekly menu plan. Woodlarks Workshop DS0000013841.V291581.R01.S.doc Version 5.2 Page 11 Staff advised that information is provided to residents to assist with decisionmaking and this is in a format to suit their individual needs. All residents are to be provided with a copy of their plan when completed. All residents are involved with their care planning and sign to indicate they agree. One resident is blind and the management informed the inspector that an audiotape would be provided for this resident. One of the residents has lived in the home for 50 years and a party was being organised by the staff for the weekend. All the staff are cooking dishes from their country of origin and the inspector saw a large cake made by a member of staff for the occasion. Woodlarks Workshop DS0000013841.V291581.R01.S.doc Version 5.2 Page 12 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 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s rights and responsibilities are recognised. EVIDENCE: Staff stated that they actively encourage and support residents to be independent, to make their own choices and to live their lives as they wish, as far as they are able. Household routines are kept to a minimum and are only in place to enable residents to share their home’s facilities and to maintain harmony within the household. The degree to which residents are involved in the running of their home needs to be described in the statement of purpose. It was observed, that staff knock before entering resident’s bedrooms and that personal care is offered discreetly. Residents are addressed in the way that they prefer and this is recorded in their individual plan. Residents are registered on the electoral roll. Woodlarks Workshop DS0000013841.V291581.R01.S.doc Version 5.2 Page 13 Three residents help in a charity shop during the week and are taken in the minibus to their place of employment. The residents are also involved with the AGM of the shops. Eight residents attend Adult Education centres for various courses; they are taken by staff in the minibus or by car. Leaflets regarding concerts, cinema and a number of other activities are left by the notice board for residents to see and request if they wish to go on any trips. Several residents have requested a canal trip. All the residents have a holiday and one resident informed the inspector she was looking forward to a week on the campsite next to the home. The majority have contact with family and friends; one resident has a regular telephone call from a relative in New Zealand. Some residents attend Sunday church service and they are taken by car by the dedicated volunteers members of the church community. The inspector was informed that four residents have requested to move into independent supported living. One of the residents informed the inspector that she wants to live near Woodlarks Workshop to be able to visit her friends on a regular basis. The management of the home stated that the care managers are looking into the prospect of accommodation for the residents with the local council. The manager has recently changed the four weekly menus and a dietician has been contacted and will be visiting the home soon to speak with the residents and staff. An alternative meal is provided as well as a vegetarian meal and salad from the trolley is served daily. The main meal is at lunchtime and in the evenings a lighter cooked meal is served. Woodlarks Workshop DS0000013841.V291581.R01.S.doc Version 5.2 Page 14 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): 18, 19 and 20. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Personal care and healthcare support and assistance is planned and was seen to be provided, where needed, in a respectful and sensitive manner. However, there were some discrepancies with regards to the administration of medication. Up dates to staff training on the administration of medication needs to be undertaken. EVIDENCE: From the tour of the premises, it was clear that residents are provided with a variety of aids and equipment to assist with their independence, including tracking hoists, electrically operated beds and wheelchairs specifically designed for individuals. The inspector was informed residents are able to choose when to go to bed and when to get up and are supported to choose their own clothes, hairstyles and other aspects of personal grooming. The manager stated that the administration of medication is carried out by A nominated, “key holder”, member of staff. These members of staff are detailed on a daily handover sheet, which specifies the staffing arrangements for each shift. Shortfalls in the required standard of administering medication were noted: Woodlarks Workshop DS0000013841.V291581.R01.S.doc Version 5.2 Page 15 A resident has been administered medication, which had not been prescribed for the particular resident. The bottle was found in her bedroom on the wash hand basin, the name of the original person had been crossed off and a hand written entry with the resident’s name on had been entered on the label. There was no record of the medication being administered on the MAR sheet. Woodlarks Workshop DS0000013841.V291581.R01.S.doc Version 5.2 Page 16 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 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All required policies, procedures and practices are in place to ensure that residents are safeguarded, as far as reasonably possible, from harm or abuse, and to ensure that residents feel their views will be listened to. EVIDENCE: The recording of complaints and action taken was found to be well documented and actioned appropriately. The complaints system was designed for the residents to voice their concerns or worries and in a format that enables the residents to complete themselves or to seek the help and support of a member of staff. Residents confirmed they are able to speak freely with staff and would know how, or speak with their key worker to make a complaint if necessary. It is pleasing to note that resident’s complaints are taken seriously in Woodlarks Workshop. The inspector was informed that two complaints had been received from residents and dealt with appropriately by the management of the home. Records were seen to ensure action had been taken. All staff except one new member of staff has received training in the protection of vulnerable adults and are aware of the whistle blowing policy. The home needs to implement a policy and procedure for managing resident’s finances. The inspector was informed that one resident has taken control of his or her own finances, hopefully this resident will be able to move into supported living in the very near future. Woodlarks Workshop DS0000013841.V291581.R01.S.doc Version 5.2 Page 17 Woodlarks Workshop DS0000013841.V291581.R01.S.doc Version 5.2 Page 18 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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The location and layout of the home is suitable for it’s stated purpose. It is accessible, safe and reasonably well maintained. The home was found to meet residents’ individual and collective needs in a comfortable and homely way. EVIDENCE: The home is homely and residents confirmed they enjoy living in the home. New fire doors have been fitted on all bedroom doors and each door has a selfclosure and all doors have been fitted with new locks. Some of the doors have been fitted with a handrail on the outside of the door the handrails were fitted at the request of the individual residents. Several bedrooms have been newly decorated and all residents were happy to show the inspector their bedroom. One resident has a budgie, the resident demonstrated how she cares for the budgie and does the necessary cleaning of the cage. There are several areas around the home that require attention; these include one of the resident’s bedroom chairs needs cleaning. Several beds were without a mattress cover, and the fluorescent lighting in a resident’s bedroom Woodlarks Workshop DS0000013841.V291581.R01.S.doc Version 5.2 Page 19 was without a cover, Management to review the use of fluorescent lighting in bedrooms. A bathroom on the ground floor was found without a lock this has been a requirement carried forward on more than one occasion. The air conditioning in the kitchen was leaking on the day of the visit and a plastic container was underneath the unit catching the over flow of water. Several new bins are required in resident’s bedrooms. And the staff sleep over room needs a new carpet. Generally the premises were found to be clean and hygienic. The laundry area is able to accommodate all the residents who are able to do their own laundry, some with assistance from staff. Management to review the charging, for the use of washing liquid product used and paid for by the residents. As part of the care provided laundry is part of the package. Woodlarks Workshop DS0000013841.V291581.R01.S.doc Version 5.2 Page 20 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 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a comprehensive staff recruitment procedure, which is designed to ensure, as far as reasonably possible, that residents are supported and protected. EVIDENCE: It was pleasing to note that staff have a good understanding of the residents needs, are respectful and have a good rapport with the residents. Both residents and staff confirmed that working relationships had greatly improved in the home. However, one resident stated that one member of staff does not speak with her, because of a disagreement they had. This information was feedback to management to be rectified. Staff recruitment files need to contain all the relevant documents as detailed in Schedule 2 of The Care Homes Regulations 2001. It was noted that all staff has had a criminal record bureau (CRB) check and Protection of Vulnerable Adult (POVA) check prior to starting work in the home. The inspector informed management that they must ensure relevant details from the agency of all agency staff are obtained prior to working in the home Staff supervision is being undertaken on a regular basis, and staff should be provided with a copy. All new staff are closely supervised for one month Woodlarks Workshop DS0000013841.V291581.R01.S.doc Version 5.2 Page 21 during the probation period. The management of the home needs to produce a training programme, to enable management to identify when staff require up dates to their training. A number of training courses have been undertaken and all new staff receives an induction programme, which is covered over several weeks. All staff should be provided with a copy of General Social Council and Care document. Two members of staff are currently undertaking NVQ Level 2 and six staff are in the process of completing NVQ Level 3. The inspector had a meeting with staff members and it was confirmed by the staff that all staff and residents had received training in equality and diversity. Which had proved beneficial to all. Positive comments were received regarding the management of the home and working conditions. All staff confirmed they are able to discuss any issues with either of the new deputy managers. Staff confirmed they enjoy going out with residents at the weekends shopping etc. and now feel part of the team. Management of the home have developed a new method of getting to know the staff. After the residents monthly meeting each month a member of staff does a presentation to the residents informing them of their background, childhood and their families. This has proved to be very interesting on the first meeting and some residents stated they were unaware of some of the content and information including photographs shown to the residents of the staff’s background. All members of staff are to undertake this role over the next few months. Woodlarks Workshop DS0000013841.V291581.R01.S.doc Version 5.2 Page 22 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, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from the management approach at the home providing an open, positive and inclusive atmosphere. The systems for resident’s consultation are varied and have been devised specifically to enable the residents to make their views known. The home would greatly benefit from a regular monthly visit by a responsible person. EVIDENCE: The manager and both deputy managers are in the process of completing the registered managers award. Both deputy managers are new to the post and residents confirmed they are more than satisfied with their management skills. Management of the home to produce a policy and procedure for managing resident’s finances. It was disappointing to note the Regulation 26 visit, had still not been undertaken, by a responsible person. The chairman can delegate a person Woodlarks Workshop DS0000013841.V291581.R01.S.doc Version 5.2 Page 23 from outside the home to undertake this visit on a monthly basis and to complete a report on their findings. The report is used as a quality audit of the home for management purposes. It was noted in a resident’s bedroom that her kettle for making hot drinks was balancing on a small box between two small items of furniture. The plug was some distance from the kettle and this was the only position that the resident was able to boil the kettle. The plug and lead of the kettle was very short and was a potential hazard. The inspector advised the home to move the plug to a more suitable position and to provide an extension table top to the wash basin so that the kettle is away from the potential water from the wash basin and easier for the resident to use. At the time of the tour of the premises it was noted that in one of the residents bedroom he has two fluorescent lights and one was without a cover, this could be a potential hazard and danger to the resident who is registered blind. Management were advised to consider changing the lighting in this bedroom. It was also noted in this bedroom that a cleaning spray of domestos was found under the washbasin. All cleaning materials must be stored in a locked cupboard at all times. In another bedroom it was noted that bathroom cleanser was found in an unlocked cupboard and the bedroom was not locked either. If residents wish to have cleaning materials in their bedrooms, they must ensure cleaning materials are kept in a locked facility or their bedroom is kept locked for the safety of the other residents. If residents are able to hold hazardous substances this must be clearly entered on their care plan and a risk assessment must be undertaken. In the kitchen the air cooler was leaking and a container was placed underneath to catch the water. This is a health and safety hazard and must be attended to before a member of staff has a serious accident. In the hallway there were three tins of paint, the inspector was informed that the maintenance person would be using the paint very shortly. However, paint must be stored in a lockable facility at all times. Woodlarks Workshop DS0000013841.V291581.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X X X 2 X X 2 X Woodlarks Workshop DS0000013841.V291581.R01.S.doc Version 5.2 Page 25 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 YA26 Regulation 43 Requirement For monthly unannounced visits to be conducted in accordance with this Regulation by the Responsible Individual for the management of the Trust. A written report must be Conducted on the home and a copy supplied to the Registered manager and the Commission. (Time Scales of 30/07/04; 21/01/05; 10/06/05; 28/10/05, 02/12/05 not met). A two-way lock is required on the lower ground floor bathroom. (Timescale 17/12/04, 20/05/05, 28/10/05 not met). An annual development plan is to be produced. (Timescale 21/02/05, 10/06/05,11/05/05 not met). The service users guide must contain relevant information as stated in schedule 1. (Timescale 21/10/05 not met). Full recruitment procedures must be followed as stated in Schedule 2 of the Care Homes Regulations 2001 (Timescale of 28/10/05 not met). Restrictors on all windows to be DS0000013841.V291581.R01.S.doc Timescale for action 23/06/06 2 YA12 23 23/06/06 3 YA17 25 14/07/06 4 YA1 5 30/06/06 5 YA34 18 09/06/06 6 YA42 23 23/06/06 Page 26 Woodlarks Workshop Version 5.2 7 YA1 4 8 YA20 13 9 10 11 12 13 14 15 16 17 18 19 YA24 YA24 YA24 YA24 YA24 YA24 YA26 YA34 YA40 YA42 YA42 16 23 23 23 13 16 16 18 25 13 13 20 21 YA42 YA42 13 13 replaced or repaired. (Timescale 28/10/05 not met). The statement of purpose to be updated to include relevant details as specified in Schedule 1 of the Care Homes Regulations 2001. Medication prescribed for one resident must not be administered to another resident. The air cooler in the kitchen needs attention. A chair in a resident’s bedroom needs cleaning. Mattress covers required on all beds. New carpet required in staff sleeping in room. Fluorescent light in a resident’s bedroom needs a cover. Waste bins in resident’s bedrooms must be emptied daily. Some residents waste bins need replacing. Management of the home to obtain details of agency staff before employment in the home. Management of the home to produce a policy and procedure regarding resident’s finances. The paint currently left in the hallway to be stored appropriately. Staff must not placed soiled rubber gloves in residents waste bins or leave in residents bedrooms. All cleaning materials to be stored in a locked cupboard at all times. To change the position of the kettle in a residents bedroom. 30/06/06 19/05/06 23/06/06 16/06/06 16/06/06 28/07/06 19/05/06 19/05/06 02/06/06 19/05/06 23/06/06 19/05/06 19/05/06 19/05/06 19/05/06 Woodlarks Workshop DS0000013841.V291581.R01.S.doc Version 5.2 Page 27 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 2 3 4 5 6 Refer to Standard YA30 YA29 YA29 YA7 YA35 YA31 Good Practice Recommendations Staff must not leave residents dirty clothes on bedroom floor. Management to consider changing the fluorescent lights in a resident’s bedroom. Management to review the fee charged to residents for washing powder for the laundry machines. To ensure all residents have agreed and signed to pay for transport. Details must be held on care plan. A training plan to be produced. All staff to be provided with a copy of the General social and Care document. Woodlarks Workshop DS0000013841.V291581.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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. 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