Inspection on 30/08/05 for Woodlarks Workshop

This inspection was carried out on 30th August 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

Woodlarks Workshop 06/12/07

Woodlarks Workshop 13/03/07

Woodlarks Workshop 19/05/06

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 Announced 30 August 2005 10.00 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. Woodlarks Workshop Document1 Version 1.40 Page 3 SERVICE INFORMATION Name of service Woodlarks Workshop Address Lodge Hill Road Farnham Surrey GU10 3RB 01252 714041 01252731600 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) Woodlarks Workshop Trust Mrs Moira Joan Woodage Care Home (PC) 22 Category(ies) of Physical disability over 65 years of age PD(E) 4 registration, with number Physical disability (PD) -18 of places Sensory impairment (SI)- 1 Male Woodlarks Workshop Document1 Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1: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 2:One service user with a sensory impairment Date of last inspection 4th May 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 Document1 Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection to be undertaken by the Commission for Social Care Inspection for the year April 2005 to March 2006. The inspection was over a period of 10 hours. For details of how each standard was met please refer to the main body of the report. It will be necessary to review both inspection reports for 2005-06 to obtain a full understanding of the extent to which the home meets The National Minimum Standards for Younger Adult. It was disappointing to note that a number of requirements made at the previous inspection had not been met. Out of the 34 requirements made eleven were still outstanding, some of these requirements have been carried over from the last two inspections December 2004 and May 2005 and one from June 2004. It was necessary on the day of inspection to make three immediate requirements regarding medication and cleaning materials left under the kitchen work surface. A serious concern letter was sent to the management of the home. The inspection was announced, which meant that visitors, staff and residents were aware of the inspection prior to it commencing. The inspectors had the opportunity to speak with a number of residents who live at the home. The majority were very complimentary about the home and staff. Nineteen residents comments were provided on a feedback card mainly with the help and support of staff, nine comments were positive the majority of comments stated residents were satisfied with the home, however, activities were not stimulating. Various other comments were made relating to the care received and this information was related to the registered manager. A full tour of the premises was undertaken. Five care plans were observed and three staff files were inspected. Four members of staff were spoken with during the inspection as well as ten residents. Two comment cards were received from care managers and two G.Ps the majority of comments were positive. Seven relatives/visitors comments were received and three were positive and four made various comments regarding not aware of various procedures within the home. These comments were passed onto the registered manager to ensure relatives/visitors are made aware of the homes policies and procedures. Mrs V Bulbeck, Lead Inspector for the service and Mrs S Holland Regulation Inspector carried out the inspection. Mrs M Woodage, Registered Manager was present. The home is registered for twenty-two places. There are currently twenty-one residents living in the home. Woodlarks Workshop Document1 Version 1.40 Page 6 The staff were observed to be courteous and the atmosphere within the home was relaxed and friendly. The inspectors wish to thank the residents and staff for their co-operation 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. What the service does well: What has improved since the last inspection? What they could do better: The home needs to ensure the requirements made are adhered to and the inspector to be informed if for any reason these requirements are not being met. At the time of the last inspection, a requirement was made that staff administering medication must be trained and the manager stated that four staff have now completed their training. It is of serious concern that other members of staff, who have not completed training, are being permitted to administer medication and this must not be allowed to continue. On the day of inspection the inspector advised the registered manager that all staff that have not completed medication training must cease administering medication until appropriately trained. Woodlarks Workshop H58 - H09 s13841 Woodlarks Workshop v235803 300805 Stage 4.doc Version 1.40 Page 7 Staff training needs to be undertaken on all staff administering medication including the registered manager who must have up to date training. 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 H58 - H09 s13841 Woodlarks Workshop v235803 300805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Woodlarks Workshop H58 - H09 s13841 Woodlarks Workshop v235803 300805 Stage 4.doc Version 1.40 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 standard(s) 1 &2. A resident’s (service user’s) guide is available but needs to be reviewed. The needs of prospective residents are assessed, but the format needs to be reviewed. EVIDENCE: A resident’s guide to the home and the services it offers has been drawn up and was supplied to the inspectors. This document should contain all the information stated in Schedule 1 of The Care Homes Regulations, but unfortunately a number of areas required were missing. Items of information, including the name and address of the registered manager and the registered provider, the qualifications and experience of members of staff, the complaints procedure and the number and sizes of rooms, are not specified. The resident’s guide stated that it would be kept under regular review and a review date of August 2005 was stated. The planned review had not been carried out at the time of inspection. The registered manager stated that the home carries out a pre-admission assessment of prospective residents, to ensure that the home can meet their needs. The assessment of the most recently arrived resident was seen and it was noted that this had not been signed or dated and there was no indication as to who had carried it out. It was also noted that the assessment format does not meet the requirements of the National Minimum Standards (NMS). It Woodlarks Workshop H58 - H09 s13841 Woodlarks Workshop v235803 300805 Stage 4.doc Version 1.40 Page 10 is recommended that the format of the pre-admission assessment be reviewed and revised. As the pre-admission assessment is not signed or dated, it is not clear who carried it out. It is required, that assessments are only carried out by staff that are suitably qualified or suitably trained. Woodlarks Workshop H58 - H09 s13841 Woodlarks Workshop v235803 300805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 & 9. An individual plan is drawn up for each resident but these need to be completed and updated. EVIDENCE: The individual plans for a number of residents were seen. Some of these were in the format that the home has used for some time and for others, the information from the older style plan was being transferred to a newer, recently adopted style. It was noted that many of the newer plans were only partially completed and many had not been signed or dated by the person completing them. In some cases, the resident had not signed the plan to show that they had been involved in drawing it up. The lack of adequate, up to date information in the individual plans makes it difficult for staff to be aware of residents’ support needs. The individual plan for one resident with heavy support needs had been completed in very few areas. This must not be allowed to continue. Individual plans must be fully completed and accurately convey all the support needs of the resident to which they refer, in order that staff can provide appropriate support and assistance. Woodlarks Workshop H58 - H09 s13841 Woodlarks Workshop v235803 300805 Stage 4.doc Version 1.40 Page 12 Staff were seen to knock before entering resident’s bedrooms, and in the absence of one resident the bedroom was not entered. Residents advised that they are supported to make decisions, such as choosing holidays. The manager stated that areas of risk to the health and welfare of residents are identified, assessed and recorded. Risk assessments covering selfadministration of medication, falls, scalding whilst making hot drinks and personal care are drawn up and were seen. It was noted that in a number of cases, significant risks to residents such as moving and handling for residents who have mobility difficulties, or the risks associated with epileptic seizures, had not been risk assessed. In other cases, the risk assessments seen were minimal in content, did not adequately assess the risks involved or changes to an existing risk and had not been updated for a long time. The manager stated that risk assessments are carried out by key workers but also stated that they have not been trained to do this. This potentially puts residents at risk as untrained staff may not recognise hazards or have sufficient knowledge of control measures to minimise risks. This must not be allowed to continue and it is required that only staff who are appropriately trained, carry out risk assessments. Woodlarks Workshop H58 - H09 s13841 Woodlarks Workshop v235803 300805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 16 & 17. The workshop at Woodlarks provides residents’ with day-to-day occupation. EVIDENCE: The workshop manager stated that residents are encouraged to take part in the daily activities, which are organised in the workshop. These include a range of craft and art based activities, such as glass painting, silk printing, weaving and woodwork. Items produced are available for sale to visitors of the home and are also sold at craft fairs and coffee mornings. The home’s statement of purpose also states that residents are expected to attend the workshop during the period usually accepted as “normal working hours”. Residents advised that they are able to attend local colleges of adult education and one resident was considering this option. Residents spoke of social events and outings they had taken part in and many had photographs of the events displayed in their rooms. Residents also Woodlarks Workshop H58 - H09 s13841 Woodlarks Workshop v235803 300805 Stage 4.doc Version 1.40 Page 14 advised that they join in activities that take place on the campsite that adjoins the home, which is used by a variety of community groups. It is clear that residents’ integration into the local community is limited by the isolated location of the home. It is situated in a semi-rural position a few miles outside the nearest local town and can only be accessed by car/mini-bus, which hinders residents’ independence. The manager advised that residents pay a weekly contribution towards transport costs and the home’s three vehicles, are usually driven by volunteer drivers. Residents’ stated that their access to the home’s transport is limited by the availability of volunteer drivers for the vehicles. Staff advised that residents have suggested to the management committee, that a paid driver is employed but the response to this is not known. The manager advised that residents are provided with a key to their bedroom and the bedrooms of residents who were absent from the home, were seen to be locked on the day of inspection. Residents stated the food was generally good. However, one resident stated that the plates are removed very quickly from the table by staff once a resident has finished eating. The cook has been working in the home for some time and has got to know the likes and dislikes of the residents. The menu indicated being well balanced and nutritious in content. The food storage area was found to be clean and well managed. The home has recently had a visit from the Environmental Health Officer and the report indicated the home was operating to a good standard. However, on the day of inspection it was noted fresh vegetables were being stored on the floor, all vegetables need to be stored off the floor. This was discussed at the time of the inspection and it was agreed that shelves would be fitted to accommodate fresh vegetables. Woodlarks Workshop H58 - H09 s13841 Woodlarks Workshop v235803 300805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 & 20. Residents’ healthcare needs are well met. The administration of medication potentially places residents at risk. 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, adjustable, electrically operated beds and wheelchairs specifically designed for individuals. Residents stated that they 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. From the individual plans and speaking to residents, it was evident that a number of healthcare professionals are involved in the support of the residents. These include general practitioners (G.P.), chiropodists, opticians, dentists and hospital specialists. The manager stated that the administration of medication is carried out by nominated, “key holder”, members of staff. These members of staff are detailed on a daily handover sheet, which specifies the staffing arrangements for each shift. At the last inspection, a requirement was made that staff administering medication must be trained and the manager stated that four staff have now completed their training. It is of serious concern that other Woodlarks Workshop H58 - H09 s13841 Woodlarks Workshop v235803 300805 Stage 4.doc Version 1.40 Page 16 members of staff, who have not completed training, are being permitted to administer medication and this must not be allowed to continue. A number of other shortfalls in the required standard of administering medication were noted: • Gaps were present on the medication administration record (MAR) sheet. • The receipt of medication into the home is not being recorded effectively or consistently, as on some occasions it is only listed and dated but not signed for. • A resident receiving medication was signing the controlled drug (CD) register as a witness, a role, which must be carried out by a second member of staff. • Administration of CD medication was not being recorded on the MAR sheet. The manager advised this was because the record was being made in the CD register but this is inadequate and unacceptable. • The prescribed dosage of a medication had been altered on a MAR sheet. • Medications that had been dropped and disposed of were not recorded accurately on the MAR sheet. • Medication was taken out of sequence in the blister packs that medication is supplied in, which is designed to ensure that medication is administered in the correct order. • There are no divisions or photographs of residents between each MAR sheet, which help to prevent the administration of medication to the wrong resident. It is of great concern that these shortfalls are still occurring, as the CSCI pharmacist inspector has also inspected the home on two occasions and provided guidance on the standard required. Woodlarks Workshop H58 - H09 s13841 Woodlarks Workshop v235803 300805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 &23. Policies are in place to protect residents from abuse and neglect but lack of staff training and recruitment procedures are placing them at possible risk of harm and abuse. Staff are aware of their responsibilities in the protection of residents EVIDENCE: The home has received one recorded complaint since the previous inspection, a meeting has been arranged with the resident, relative and persons indicated in the complaint, the registered manager and care manager to attend a meeting to discuss the content of the complaint and to proceed forward with any issues resulting from the complaint. Further to speaking with the staff, it was clear that they are aware of their responsibilities in the protection of residents. The home holds a copy of the Surrey Multi Agency Procedure for the Protection Of Vulnerable Adults. This procedure would be followed in the event of concerns being raised about residents being, or at risk of being abused in any way. Staff stated that they have undertaken training in the protection of vulnerable adults, although the staff training record showed that some staff has not undertaken this for a number of years. Staff are aware of their responsibility to report any concerns they have and stated that they would report any concerns to the appropriate agency. It is recommended that training for staff in the protection of vulnerable adults be carried out on a regular basis. Woodlarks Workshop H58 - H09 s13841 Woodlarks Workshop v235803 300805 Stage 4.doc Version 1.40 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 standard(s) 24, 27 &30. The location of the home is some distance from the town centre and transport is required. The home was found to meet the majority of residents’ individual and collective needs in a comfortable and homely way. EVIDENCE: Residents bedrooms were comfortable and homely, the majority of residents maintain their own cleaning and generally independent. On the day of inspection all the bedrooms were seen and found to be comfortable and all residents have personalised their bedroom with various items. The home has two contract cleaners on a daily basis Monday to Friday for two hours a day. During weekends staff undertake cleaning duties, therefore this practice does not enable staff to spend time with residents and weekends seem to be a dull time with little or nothing to interest the residents. The transport arrangements need to be reviewed. It was noted in one of the residents meetings minutes undertaken in the workshop that residents do not want their bedrooms tidied as they are not able to find things. However, Care staff need to ensure residents bedroom are kept clean and the key worker should be able to work with the residents. A number of areas in the home have been up graded; these include redecoration in hallways and corridors. There are also a few areas that require Woodlarks Workshop H58 - H09 s13841 Woodlarks Workshop v235803 300805 Stage 4.doc Version 1.40 Page 19 attention these include: the bathroom on the lower ground floor needs a new rubber non-slip floor mat. The ceiling was also leaking. Another bathroom on the lower ground floor was without a lock on the door; this was identified at the previous inspection. In a toilet the walls need attention and decorating. The fire door in the small lounge on the lower ground floor was not closing. In a residents bedroom a television needs to be mounted on a wall bracket to ensure the resident is safe from the T.V falling on her. This was made a requirement at the previous inspection when the T.V was mounted on a pile on books. Woodlarks Workshop H58 - H09 s13841 Woodlarks Workshop v235803 300805 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 35 & 36. All interactions observed between staff and residents evidenced a high degree of respect and skill in working with the individual residents at the home. Staffing levels need to be kept under review and provided to meet the needs of the residents at all times. Action must be taken to improve the staff training and recruitment procedures. EVIDENCE: Staff stated that their complaints are not listened to by the home’s management. Some staff feel they are discriminated against, particularly by one member of staff. Staff commented that the staff meetings are not effective as no agenda is drawn up, staff are not offered the chance to contribute, and it is not an appropriate place to discuss some concerns, and minutes of the meetings have only been produced once. It was also stated that the registered provider does not acknowledge staff when he attends the home. The Registered manager stated and staff confirmed, that supervision of staff has not taken place. The manager advised that she and the deputy manager had recently undertaken supervision training. A number of staff require up to date training, this should include all mandatory training, as well as more specialised training. Medication training needs to be undertaken as a priority. In the meantime staff that have not received the Woodlarks Workshop H58 - H09 s13841 Woodlarks Workshop v235803 300805 Stage 4.doc Version 1.40 Page 21 relevant medication training must not undertake the administering of medication. Recruitment procedures need to be followed. All staff should have a contract and training qualifications should be held on file as well as relevant documentation detailed in schedule 2. Woodlarks Workshop H58 - H09 s13841 Woodlarks Workshop v235803 300805 Stage 4.doc Version 1.40 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 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) 37, 39 & 42. The systems for resident’s consultation are varied and have been devised specifically to enable the residents to make their views known, in their working environment where the meetings are held. Action must be taken to ensure that staff training promotes and protects the health, safety and welfare of residents. EVIDENCE: The registered manager has enrolled to undertake the Registered Managers Award but has not started the course; therefore the deadline for completing the course being 2005 will not be met. There is also a need for the registered manager to have updates to a number of other training courses. The overall responsibility of the registered manager must ensure the home complies with the Care Standards Act and Regulations. As well as General Social Care Council codes of practice and other legal requirements. Management needs to introduce a monitoring system in place to measure success in achieving the aims and objectives and statement of purpose of the home. Woodlarks Workshop H58 - H09 s13841 Woodlarks Workshop v235803 300805 Stage 4.doc Version 1.40 Page 23 A number of residents stated that they did not know who was in charge when the manager was absent from the home. A system needs to be introduced to inform residents who are in charge and who is responsible. A number of records were observed these include the accident book, fire records, training as well as health and safety records. It was noted that not all visitors sign the visitors book this is a legal requirement to ensure in the event of an emergency in the home, clear records are maintained for health and safety purposes. There were a number of gaps in the weekly recording of the fire alarm system. There is a need to produce a fire risk assessment on the whole building room by room. It was pleasing to note that a recent fire drill undertaken on 28/07/05, the building was cleared within three minutes. However, the key holder did not phone the fire service. Action has been taken by the home to ensure this practice does not happen again. It was noted that cleaning materials were found under the kitchen sink, all hazardous substances must be stored in a lockable facility at all times. It was also noted that pine cleaner was found in the staff toilet. The cupboard containing decorating materials to be kept locked when not in use. It is recommended that the product information sheets for substances hazardous to health are stored with the products to which they refer, for ease of access in the event of an emergency. During the inspection the inspectors were informed the microwave in the kitchen is used to warm bags used for the residents. It is not appropriate for food to be warmed in this microwave. The registered manager informed the inspectors she had been provided with the money to purchase a new microwave but had not had time to purchase one. A number of window restrictors on the upper floor windows to be reviewed to ensure that they operate properly. The manager to introduce a maintenance book to be used by the maintenance person to be able to sign when the job has been completed and to enable him to see which jobs are outstanding. Woodlarks Workshop H58 - H09 s13841 Woodlarks Workshop v235803 300805 Stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 2 x x x Standard No 22 23 ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 x 1 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 2 x x 2 Standard No 11 12 13 14 15 16 17 x 3 2 x x 3 x Standard No 31 32 33 34 35 36 Score x x 2 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Woodlarks Workshop Score 3 3 1 x Standard No 37 38 39 40 41 42 43 Score 2 x 2 x x 2 x H58 - H09 s13841 Woodlarks Workshop v235803 300805 Stage 4.doc Version 1.40 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 26 (2)-(5) Regulation 43 Requirement For monthly unannounced visits to be conducted in accordance with this regulation by the Responsible Individual or other persons responsible for the management of the Trust. A written report must be produced of these visits, on the conduct of the home and a copy supplied to the registered manager and the Commission. (Time scale of 30/07/04 & 21/01/05 10/06/05 not met) All cleaning materials must be stored in a lockable facility at all times.(Timescale of 09/12/04 04/05/05 not met) Risk assessments required for service users using the laundry facilities(Timescale of 21/01/05 20/05/05 not met) A two-way lock is required on the downstairs bathroom.(Timescale of 17/12/04 20/05/05 not met) The Responsible Individual is required to supervise the Registered Manager at regular intervals (Timescale of 21/03/05 10/06/05 not met) An Annual Development Plan is H58 - H09 s13841 Woodlarks Workshop v235803 300805 Stage 4.doc Timescale for action 28/10/05 2. 13 42 30/08/05 3. 13 9 28/10/05 4. 12 27 28/10/05 5. 18 36 28/10/05 6. 17 39 11/11/05 Page 26 Woodlarks Workshop Version 1.40 7. 8. 20 42 13 23 9. 10. 37 42 24 16 11. 42 13 12. 13. 14. 15. 1 2 6 9 5 14 15 13 16. 13 12 17. 18. 19. 20. 20 27 33 34 13 23 17 19 to be produced. (Timescale of 21/02/05 10/06/05 not met) All staff administering medication must have appropriate training. (timescale of 27/05/05 not met). The T.V stacked on books needs to be appropriately secured on a bracket (Timescale of 11/05/05 not met). The manager to complete the Registered Managers Award. Rubber gloves used by staff to be stored appropriately and not in residents bedrooms. (Timescale of 18/05/05 not met). A fire risk assessment to be completed on the whole of the premises. (Timescale of 17/06/05 not met). The service users guide must contain relevant information as stated in Schedule 1. Pre-admission assessment of service users to be undertaken and to be signed and dated. Service user’s plan to made available to service user and kept under review. Apropriate risk assessments to be undertaken by qualified staff to ensure the health and safety of residents. Transport arrangements to be reviewed, to enable residents access to the local community on a more regualr basis. Medication procedures must be followed and reviewed on a regular basis. The toilet walls need attention and decorating lower ground. Staff and residents meetings to be held including an agenda and minutes taken. Full recruitment procedures must be followed. H58 - H09 s13841 Woodlarks Workshop v235803 300805 Stage 4.doc 28/10/05 28/10/05 06/11/05 09/09/05 21/10/05 21/10/05 21/10/05 21/10/05 28/10/05 21/10/05 30/08/05 28/10/05 28/10/05 28/10/05 Woodlarks Workshop Version 1.40 Page 27 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 35 36 39 42 42 42 42 18 18 26 13 13 13 17 Staff training and updates to training must be undertaken. Regular supervision must be undertaken on all staff. The management to ensure a quality audit is undertaken on the home on a regular basis. The testing of the fire alarm system must be undertaken on a regular weekly basis. Restrictors on windows need to be replaced or repaired. The microwave currently used for warming bags needs replacing in the dining room. The visitors book must be signed by everyone entering the home. 05/11/05 28/10/05 28/10/05 21/10/05 28/10/05 28/10/05 01/10/05 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 23 Good Practice Recommendations All staff should receive regular up to date training on the protection of vulnerable adults. Woodlarks Workshop H58 - H09 s13841 Woodlarks Workshop v235803 300805 Stage 4.doc Version 1.40 Page 28 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI Woodlarks Workshop H58 - H09 s13841 Woodlarks Workshop v235803 300805 Stage 4.doc Version 1.40 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!